Policy Information:

Step 1 - 9

Policy #: Please type your policy number

Looks good!

Not good!

Registration number: Please type your car registration number

Date of loss: When was the date of the accident

Time of accident: At what time did the accident happen

Date reported:

Policy Holder Information:

Step 2 - 9

Policyholder Name:

Period of ins - Start date:

Period of ins - End date:

Type of cover/class:

Make & model:

Registration year :

Policyholder ID or Passport: Please type your IC number or passport number

PH Contact Number: Please give us your contact number

PH Email: Please give us your email address

Company Declaration:

Step 3 - 9

Is this a company car? No Yes

Driver's Declaration:

Step 4 - 9

Are you driving this car? Yes No

Location & Details

Step 5 - 9

Location GPS Please help pin the location of the accident

OR

Location description Please describe where the accident occurred as best as you can

Type of Road Please choose one

Road conditions Please choose one

Weather: Please choose one

Description of loss:

Accident additional details:

Step 6 - 9

Was any government property involved? No Yes
Was anyone injured in the accident? : No Yes

Workshop:

Step 7 - 9

Workshop: Please choose one

Was any Third Party involved? : No Yes

Third Party's name : Please us their name (if possible)

Third Party's contact # : Please give us their contact number (if possible)

Third Party's car registration number: Please give us their car registration

Third Party's insurance company : If you know where they are insured … please choose one

Upload:

Step 8 - 9

Photos of accident: Max size: 10mb each photo
Max number: 10 photos only

Policyholder ID or Passport: Max size: 10mb each photo
Max number: 2 photos only

Driver's ID or Passport: Max size: 10mb each photo
Max number: 2 photos only

Driver's Driving License: Max size: 10mb each photo
Max number: 2 photos only

Car registration book/card: Max size: 10mb each photo
Max number: 4 photos only

Police reports: Max size: 10mb each photo
Max number: 2 photos only

Driver's Authorisation Letter from Policyholder : Max size: 10mb each photo
Max number: 2 photos only

Declaration:

Step 9 - 9

I/We to the best of my/our knowledge hereby declare that the above statements and particulars are correct and complete in every respect and I/We have not concealed, misrepresented or mis-stated any material fact.

Finish:

Step 9 - 9

Dear Customer, We thank you for the claims notification. Your claims reference number is ... Please note that this is not an admission of liability. Please note your claims reference number if you wish to contact us. You may call us: +673 222 6222 (ask for the Claims Department) You may email us: claims.report@national.com.bn Thank you

National e-Form

Policy Information:

Step 1 - 9

Policy Holder Information:

Step 2 - 9

Company Declaration:

Step 3 - 9

Driver's Declaration:

Step 4 - 9

Location & Details

Step 5 - 9

OR

Accident additional details:

Step 6 - 9

Workshop:

Step 7 - 9

Upload:

Step 8 - 9

Declaration:

Step 9 - 9

Finish:

Step 9 - 9