{"id":1887,"date":"2024-12-04T13:23:55","date_gmt":"2024-12-04T13:23:55","guid":{"rendered":"http:\/\/ceiil.ng\/?page_id=1887"},"modified":"2025-04-15T10:32:27","modified_gmt":"2025-04-15T10:32:27","slug":"motor-insurance-claim-2","status":"publish","type":"page","link":"http:\/\/ceiil.ng\/index.php\/motor-insurance-claim-2\/","title":{"rendered":"Motor Insurance Claim"},"content":{"rendered":"\t\t
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CLAIM FORM<\/h2><\/div>\n <\/section>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t
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Motor Claim Form<\/a>\u00a0<\/p>

Fire Claim Form<\/a><\/p>

All Risk Claim Form<\/a><\/p>

\u00a0<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t

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\n\t\t\t\t\t\r\n\r\n\r\n\r\n \r\n \r\n All Risk Claim Form<\/title>\r\n <style>\r\n \/* Enhanced Styling *\/\r\n body {\r\n font-family: Arial, sans-serif;\r\n line-height: 1.6;\r\n margin: 20px;\r\n background-color: #f4f4f4;\r\n }\r\n\r\n .container {\r\n max-width: 800px;\r\n margin: 0 auto;\r\n background-color: #fff;\r\n padding: 20px;\r\n border-radius: 8px;\r\n box-shadow: 0 0 10px rgba(0, 0, 0, 0.1);\r\n }\r\n\r\n h1 {\r\n text-align: center;\r\n color: #333;\r\n }\r\n\r\n .form-group {\r\n margin-bottom: 15px;\r\n }\r\n\r\n label {\r\n display: block;\r\n margin-bottom: 5px;\r\n font-weight: bold;\r\n color: #555;\r\n }\r\n\r\n input[type=\"text\"],\r\n input[type=\"email\"],\r\n input[type=\"tel\"],\r\n textarea {\r\n width: 100%;\r\n padding: 10px;\r\n border: 1px solid #ddd;\r\n border-radius: 4px;\r\n box-sizing: border-box; \/* Important for padding *\/\r\n }\r\n\r\n textarea {\r\n resize: vertical;\r\n min-height: 100px;\r\n }\r\n\r\n table {\r\n width: 100%;\r\n border-collapse: collapse;\r\n margin-top: 20px;\r\n }\r\n\r\n table,\r\n th,\r\n td {\r\n border: 1px solid #ddd;\r\n padding: 10px;\r\n text-align: left;\r\n }\r\n\r\n th {\r\n background-color: #f9f9f9;\r\n font-weight: bold;\r\n color: #333;\r\n }\r\n\r\n .notice {\r\n font-style: italic;\r\n color: #777;\r\n margin-top: 10px;\r\n }\r\n\r\n button[type=\"submit\"] {\r\n background-color: #4CAF50;\r\n color: white;\r\n padding: 12px 20px;\r\n border: none;\r\n border-radius: 4px;\r\n cursor: pointer;\r\n font-size: 16px;\r\n }\r\n\r\n button[type=\"submit\"]:hover {\r\n background-color: #45a049;\r\n }\r\n\r\n .error {\r\n color: red;\r\n font-size: 0.8em;\r\n margin-top: 5px;\r\n }\r\n <\/style>\r\n<\/head>\r\n\r\n<body>\r\n <div class=\"container\">\r\n <h1>ALL RISK CLAIM FORM<\/h1>\r\n <form action=\"submit-claim.php\" method=\"POST\" onsubmit=\"return validateForm()\">\r\n\r\n <div class=\"form-group\">\r\n <label for=\"policyNumber\">Policy Number<\/label>\r\n <input type=\"text\" id=\"policyNumber\" name=\"policyNumber\" required>\r\n <span id=\"policyNumberError\" class=\"error\"><\/span>\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label for=\"claimNumber\">Claim Number<\/label>\r\n <input type=\"text\" id=\"claimNumber\" name=\"claimNumber\">\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label for=\"insuredName\">Insured\u2019s Name in full<\/label>\r\n <input type=\"text\" id=\"insuredName\" name=\"insuredName\" required>\r\n <span id=\"insuredNameError\" class=\"error\"><\/span>\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label for=\"address\">Address<\/label>\r\n <textarea id=\"address\" name=\"address\" required><\/textarea>\r\n <span id=\"addressError\" class=\"error\"><\/span>\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label for=\"occupation\">Occupation<\/label>\r\n <input type=\"text\" id=\"occupation\" name=\"occupation\">\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label for=\"telephoneNumber\">Telephone Number<\/label>\r\n <input type=\"tel\" id=\"telephoneNumber\" name=\"telephoneNumber\">\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label for=\"emailAddress\">Email Address<\/label>\r\n <input type=\"email\" id=\"emailAddress\" name=\"emailAddress\" required>\r\n <span id=\"emailAddressError\" class=\"error\"><\/span>\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label for=\"inceptionRenewalDate\">Inception date \/ Renewal date<\/label>\r\n <input type=\"text\" id=\"inceptionRenewalDate\" name=\"inceptionRenewalDate\">\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label for=\"natureOfLoss\">Nature of Loss<\/label>\r\n <input type=\"text\" id=\"natureOfLoss\" name=\"natureOfLoss\" required>\r\n <span id=\"natureOfLossError\" class=\"error\"><\/span>\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label for=\"circumstancesOfLoss\">Describe the full circumstances of the loss, stating the date and time<\/label>\r\n <textarea id=\"circumstancesOfLoss\" name=\"circumstancesOfLoss\" required><\/textarea>\r\n <span id=\"circumstancesOfLossError\" class=\"error\"><\/span>\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label for=\"suspectPerson\">Do you suspect any person in connection therewith?<\/label>\r\n <textarea id=\"suspectPerson\" name=\"suspectPerson\"><\/textarea>\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label for=\"policeAdvisedDateAddress\">The date police was advised and the address of the station<\/label>\r\n <textarea id=\"policeAdvisedDateAddress\" name=\"policeAdvisedDateAddress\"><\/textarea>\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label for=\"stepsToRecoverProperty\">What other steps have been taken to recover the property? Please give full\r\n details<\/label>\r\n <textarea id=\"stepsToRecoverProperty\" name=\"stepsToRecoverProperty\"><\/textarea>\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label for=\"otherInsurances\">Are there any other insurances against this loss?<\/label>\r\n <textarea id=\"otherInsurances\" name=\"otherInsurances\"><\/textarea>\r\n <\/div>\r\n\r\n <h2>PARTICULARS OF CLAIM<\/h2>\r\n\r\n <table>\r\n <thead>\r\n <tr>\r\n <th>No. of Article<\/th>\r\n <th>Full Description<\/th>\r\n <th>Name and address of seller<\/th>\r\n <th>Date of purchase<\/th>\r\n <th>Cost Paid<\/th>\r\n <th>Amount of Claim<\/th>\r\n <\/tr>\r\n <\/thead>\r\n <tbody>\r\n <tr>\r\n <td><input type=\"text\" name=\"articleNo[]\"><\/td>\r\n <td><input type=\"text\" name=\"fullDescription[]\"><\/td>\r\n <td><input type=\"text\" name=\"sellerNameAddress[]\"><\/td>\r\n <td><input type=\"text\" name=\"purchaseDate[]\"><\/td>\r\n <td><input type=\"text\" name=\"costPaid[]\"><\/td>\r\n <td><input type=\"text\" name=\"amountClaimed[]\"><\/td>\r\n <\/tr>\r\n <tr>\r\n <td><input type=\"text\" name=\"articleNo[]\"><\/td>\r\n <td><input type=\"text\" name=\"fullDescription[]\"><\/td>\r\n <td><input type=\"text\" name=\"sellerNameAddress[]\"><\/td>\r\n <td><input type=\"text\" name=\"purchaseDate[]\"><\/td>\r\n <td><input type=\"text\" name=\"costPaid[]\"><\/td>\r\n <td><input type=\"text\" name=\"amountClaimed[]\"><\/td>\r\n <\/tr>\r\n <tr>\r\n <td><input type=\"text\" name=\"articleNo[]\"><\/td>\r\n <td><input type=\"text\" name=\"fullDescription[]\"><\/td>\r\n <td><input type=\"text\" name=\"sellerNameAddress[]\"><\/td>\r\n <td><input type=\"text\" name=\"purchaseDate[]\"><\/td>\r\n <td><input type=\"text\" name=\"costPaid[]\"><\/td>\r\n <td><input type=\"text\" name=\"amountClaimed[]\"><\/td>\r\n <\/tr>\r\n <tr>\r\n <td><input type=\"text\" name=\"articleNo[]\"><\/td>\r\n <td><input type=\"text\" name=\"fullDescription[]\"><\/td>\r\n <td><input type=\"text\" name=\"sellerNameAddress[]\"><\/td>\r\n <td><input type=\"text\" name=\"purchaseDate[]\"><\/td>\r\n <td><input type=\"text\" name=\"costPaid[]\"><\/td>\r\n <td><input type=\"text\" name=\"amountClaimed[]\"><\/td>\r\n <\/tr>\r\n <tr>\r\n <td><input type=\"text\" name=\"articleNo[]\"><\/td>\r\n <td><input type=\"text\" name=\"fullDescription[]\"><\/td>\r\n <td><input type=\"text\" name=\"sellerNameAddress[]\"><\/td>\r\n <td><input type=\"text\" name=\"purchaseDate[]\"><\/td>\r\n <td><input type=\"text\" name=\"costPaid[]\"><\/td>\r\n <td><input type=\"text\" name=\"amountClaimed[]\"><\/td>\r\n <\/tr>\r\n <tr>\r\n <td><input type=\"text\" name=\"articleNo[]\"><\/td>\r\n <td><input type=\"text\" name=\"fullDescription[]\"><\/td>\r\n <td><input type=\"text\" name=\"sellerNameAddress[]\"><\/td>\r\n <td><input type=\"text\" name=\"purchaseDate[]\"><\/td>\r\n <td><input type=\"text\" name=\"costPaid[]\"><\/td>\r\n <td><input type=\"text\" name=\"amountClaimed[]\"><\/td>\r\n <\/tr>\r\n <tr>\r\n <td><input type=\"text\" name=\"articleNo[]\"><\/td>\r\n <td><input type=\"text\" name=\"fullDescription[]\"><\/td>\r\n <td><input type=\"text\" name=\"sellerNameAddress[]\"><\/td>\r\n <td><input type=\"text\" name=\"purchaseDate[]\"><\/td>\r\n <td><input type=\"text\" name=\"costPaid[]\"><\/td>\r\n <td><input type=\"text\" name=\"amountClaimed[]\"><\/td>\r\n <\/tr>\r\n <\/tbody>\r\n <\/table>\r\n\r\n <p class=\"notice\">Special Notice: By the conditions, the policy is rendered void if any claim be fraudulent or\r\n intentionally exaggerated or if any false statement or declaration be made in support of it. It is therefore\r\n important that this form be filled with great care.<\/p>\r\n\r\n <p>I hereby declare that the within mentioned money \/ property (ies) belonging to me and insured under the said\r\n policy was lost, damaged or stolen in the circumstances stated and that in consequence thereof a claim is\r\n hereby being made for the sums severally stated within.<\/p>\r\n\r\n <div class=\"form-group\">\r\n <label for=\"witness\">Witness<\/label>\r\n <input type=\"text\" id=\"witness\" name=\"witness\">\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label for=\"signature\">Signature<\/label>\r\n <input type=\"file\" id=\"signature\" name=\"signature\" required>\r\n <span id=\"signatureError\" class=\"error\"><\/span>\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label for=\"date\">Date<\/label>\r\n <input type=\"text\" id=\"date\" name=\"date\" required>\r\n <span id=\"dateError\" class=\"error\"><\/span>\r\n <\/div>\r\n\r\n <p class=\"notice\">NB: This statement of claim should be completed and forwarded immediately to the Company.<\/p>\r\n\r\n <p>The insured must at once take every practical and reasonable step that may lead to the recovery of\r\n money\/property(ies). The police must be advised immediately and any suspicious deal as to the parties\r\n implicated must be communicated to the company without delay.<\/p>\r\n\r\n <p>Should any of the insured\u2019s money \/ property which is the subject of this claim be recovered either before or\r\n after the indemnity has been provided under the within named policy, the Company must be notified\r\n immediately.<\/p>\r\n\r\n <button type=\"submit\">Submit Claim<\/button>\r\n <\/form>\r\n <\/div>\r\n\r\n <script>\r\n function validateForm() {\r\n let isValid = true;\r\n\r\n \/\/ Simple validation - improve as needed\r\n isValid = validateField(\"policyNumber\", \"Policy Number is required\") && isValid;\r\n isValid = validateField(\"insuredName\", \"Insured's Name is required\") && isValid;\r\n isValid = validateField(\"address\", \"Address is required\") && isValid;\r\n isValid = validateField(\"emailAddress\", \"Valid Email is required\", \"email\") && isValid;\r\n isValid = validateField(\"natureOfLoss\", \"Nature of Loss is required\") && isValid;\r\n isValid = validateField(\"circumstancesOfLoss\", \"Circumstances of Loss are required\") && isValid;\r\n isValid = validateField(\"signature\", \"Signature is required\") && isValid;\r\n isValid = validateField(\"date\", \"Date is required\") && isValid;\r\n\r\n return isValid;\r\n }\r\n\r\n function validateField(fieldId, errorMessage, type = \"text\") {\r\n const field = document.getElementById(fieldId);\r\n const errorSpan = document.getElementById(fieldId + \"Error\");\r\n\r\n if (!field.value.trim()) {\r\n errorSpan.textContent = errorMessage;\r\n return false;\r\n }\r\n\r\n if (type === \"email\" && !isValidEmail(field.value)) {\r\n errorSpan.textContent = \"Invalid email format\";\r\n return false;\r\n }\r\n\r\n errorSpan.textContent = \"\"; \/\/ Clear any previous error\r\n return true;\r\n }\r\n\r\n function isValidEmail(email) {\r\n \/\/ Basic email validation regex\r\n const emailRegex = \/^[^\\s@]+@[^\\s@]+\\.[^\\s@]+$\/;\r\n return emailRegex.test(email);\r\n }\r\n <\/script>\r\n<\/body>\r\n\r\n<\/html>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-8845b6c elementor-section-boxed elementor-section-height-default elementor-section-height-default wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no\" data-id=\"8845b6c\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"aux-parallax-section elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-2aa8b1b\" data-id=\"2aa8b1b\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-c00692c elementor-widget elementor-widget-html\" data-id=\"c00692c\" data-element_type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<!DOCTYPE html>\r\n<html lang=\"en\">\r\n\r\n<head>\r\n <meta charset=\"UTF-8\">\r\n <meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\">\r\n <title>Fire \/ Material Damage Claim Form<\/title>\r\n <style>\r\n \/* Enhanced Styling *\/\r\n body {\r\n font-family: Arial, sans-serif;\r\n line-height: 1.6;\r\n margin: 20px;\r\n background-color: #f4f4f4;\r\n }\r\n\r\n .container {\r\n max-width: 800px;\r\n margin: 0 auto;\r\n background-color: #fff;\r\n padding: 20px;\r\n border-radius: 8px;\r\n box-shadow: 0 0 10px rgba(0, 0, 0, 0.1);\r\n }\r\n\r\n h1 {\r\n text-align: center;\r\n color: #333;\r\n }\r\n\r\n .form-group {\r\n margin-bottom: 15px;\r\n }\r\n\r\n label {\r\n display: block;\r\n margin-bottom: 5px;\r\n font-weight: bold;\r\n color: #555;\r\n }\r\n\r\n input[type=\"text\"],\r\n input[type=\"email\"],\r\n input[type=\"tel\"],\r\n textarea {\r\n width: 100%;\r\n padding: 10px;\r\n border: 1px solid #ddd;\r\n border-radius: 4px;\r\n box-sizing: border-box;\r\n }\r\n\r\n textarea {\r\n resize: vertical;\r\n min-height: 100px;\r\n }\r\n\r\n table {\r\n width: 100%;\r\n border-collapse: collapse;\r\n margin-top: 20px;\r\n }\r\n\r\n table,\r\n th,\r\n td {\r\n border: 1px solid #ddd;\r\n padding: 10px;\r\n text-align: left;\r\n }\r\n\r\n th {\r\n background-color: #f9f9f9;\r\n font-weight: bold;\r\n color: #333;\r\n }\r\n\r\n .notice {\r\n font-style: italic;\r\n color: #777;\r\n margin-top: 10px;\r\n }\r\n\r\n button[type=\"submit\"] {\r\n background-color: #4CAF50;\r\n color: white;\r\n padding: 12px 20px;\r\n border: none;\r\n border-radius: 4px;\r\n cursor: pointer;\r\n font-size: 16px;\r\n }\r\n\r\n button[type=\"submit\"]:hover {\r\n background-color: #45a049;\r\n }\r\n\r\n .error {\r\n color: red;\r\n font-size: 0.8em;\r\n margin-top: 5px;\r\n }\r\n <\/style>\r\n<\/head>\r\n\r\n<body>\r\n <div class=\"container\">\r\n <h1>FIRE \/ MATERIAL DAMAGE CLAIM FORM<\/h1>\r\n <form action=\"submit-fire-claim.php\" method=\"POST\" onsubmit=\"return validateForm()\">\r\n <div class=\"form-group\">\r\n <label for=\"policyNumber\">Policy Number<\/label>\r\n <input type=\"text\" id=\"policyNumber\" name=\"policyNumber\" required>\r\n <span id=\"policyNumberError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"claimNumber\">Claim Number<\/label>\r\n <input type=\"text\" id=\"claimNumber\" name=\"claimNumber\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"nameOfInsured\">Name of Insured<\/label>\r\n <input type=\"text\" id=\"nameOfInsured\" name=\"nameOfInsured\" required>\r\n <span id=\"nameOfInsuredError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"address\">Address<\/label>\r\n <textarea id=\"address\" name=\"address\" required><\/textarea>\r\n <span id=\"addressError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"occupation\">Occupation<\/label>\r\n <input type=\"text\" id=\"occupation\" name=\"occupation\" required>\r\n <span id=\"occupationError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"telephoneNumber\">Telephone Number<\/label>\r\n <input type=\"tel\" id=\"telephoneNumber\" name=\"telephoneNumber\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"emailAddress\">Email Address<\/label>\r\n <input type=\"email\" id=\"emailAddress\" name=\"emailAddress\" required>\r\n <span id=\"emailAddressError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"inceptionDate\">Inception Date<\/label>\r\n <input type=\"text\" id=\"inceptionDate\" name=\"inceptionDate\" required>\r\n <span id=\"inceptionDateError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"branchOrAgent\">Branch or Agent to whom premium was paid<\/label>\r\n <input type=\"text\" id=\"branchOrAgent\" name=\"branchOrAgent\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"tradeOccupation\">Trade \/ Occupation (state all, if more than one)<\/label>\r\n <textarea id=\"tradeOccupation\" name=\"tradeOccupation\"><\/textarea>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"situationOfPremises\">Situation of the Premises affected \/ damaged<\/label>\r\n <textarea id=\"situationOfPremises\" name=\"situationOfPremises\" required><\/textarea>\r\n <span id=\"situationOfPremisesError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"proximateCauseOfLoss\">Proximate Cause of loss \/ incident<\/label>\r\n <input type=\"text\" id=\"proximateCauseOfLoss\" name=\"proximateCauseOfLoss\" required>\r\n <span id=\"proximateCauseOfLossError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"dateOfIncident\">Date of incident \/ loss<\/label>\r\n <input type=\"text\" id=\"dateOfIncident\" name=\"dateOfIncident\" required>\r\n <span id=\"dateOfIncidentError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"detailsOfIncident\">Details of how the incident occurred<\/label>\r\n <textarea id=\"detailsOfIncident\" name=\"detailsOfIncident\" required><\/textarea>\r\n <span id=\"detailsOfIncidentError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"previousClaims\">Have you ever lodged or reported a claim or claimed against any insurer on the\r\n risk insured? If so, give details:<\/label>\r\n <textarea id=\"previousClaims\" name=\"previousClaims\"><\/textarea>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"soleOwner\">Are you the sole owner of the destroyed \/ damaged property?<\/label>\r\n <select id=\"soleOwner\" name=\"soleOwner\" required>\r\n <option value=\"\">-- Select --<\/option>\r\n <option value=\"yes\">Yes<\/option>\r\n <option value=\"no\">No<\/option>\r\n <\/select>\r\n <span id=\"soleOwnerError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"otherInterestedParties\">If no, state the name(s) of other interested parties and the nature of\r\n their interest:<\/label>\r\n <textarea id=\"otherInterestedParties\" name=\"otherInterestedParties\"><\/textarea>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"responsibleForRepair\">In respect of damage to buildings or landlord\u2019s fixtures (including internal\r\n decoration), are you responsible for repair of such damage under the terms of a tenancy agreement?<\/label>\r\n <select id=\"responsibleForRepair\" name=\"responsibleForRepair\" required>\r\n <option value=\"\">-- Select --<\/option>\r\n <option value=\"yes\">Yes<\/option>\r\n <option value=\"no\">No<\/option>\r\n <\/select>\r\n <span id=\"responsibleForRepairError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"otherInsurance\">Was there at the time of the occurrence of loss any other existing insurance\r\n effected by you or any other person(s) on the property for which this claim is being made? If so, please\r\n give details<\/label>\r\n <textarea id=\"otherInsurance\" name=\"otherInsurance\"><\/textarea>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"salvageableItems\">In view of the nature of loss \/ incident, is there going to be salvageable items?<\/label>\r\n <select id=\"salvageableItems\" name=\"salvageableItems\" required>\r\n <option value=\"\">-- Select --<\/option>\r\n <option value=\"yes\">Yes<\/option>\r\n <option value=\"no\">No<\/option>\r\n <\/select>\r\n <span id=\"salvageableItemsError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"insuredKeepingSalvage\">If yes, is the insured or property owner interested in keeping same?<\/label>\r\n <select id=\"insuredKeepingSalvage\" name=\"insuredKeepingSalvage\">\r\n <option value=\"\">-- Select --<\/option>\r\n <option value=\"yes\">Yes<\/option>\r\n <option value=\"no\">No<\/option>\r\n <\/select>\r\n <\/div>\r\n <p class=\"notice\">Any damaged property(ies) or items should not be disposed off without intimating the insurer or\r\n getting insurer\u2019s approval \/ permission.<\/p>\r\n\r\n <h2>Details of claim and estimation<\/h2>\r\n\r\n <table>\r\n <thead>\r\n <tr>\r\n <th>Particular of each building or factory or article in respect of which this claim is made<\/th>\r\n <th>Date of construction or purchased or received<\/th>\r\n <th>Name of the Contractor\/ from whom purchased or donated<\/th>\r\n <th>Original cost price<\/th>\r\n <th>Value at the time of fire destruction after given allowance for aging, wear and tear<\/th>\r\n <th>Present reinstatement cost<\/th>\r\n <th>Amount claimed after given allowance for value of salvage or cost of repairs<\/th>\r\n <\/tr>\r\n <\/thead>\r\n <tbody>\r\n <tr>\r\n <td><textarea name=\"particularBuilding[]\"><\/textarea><\/td>\r\n <td><input type=\"text\" name=\"dateConstruction[]\"><\/td>\r\n <td><input type=\"text\" name=\"nameContractor[]\"><\/td>\r\n <td><input type=\"text\" name=\"originalCostPrice[]\"><\/td>\r\n <td><input type=\"text\" name=\"valueFireDestruction[]\"><\/td>\r\n <td><input type=\"text\" name=\"presentReinstatementCost[]\"><\/td>\r\n <td><input type=\"text\" name=\"amountClaimed[]\"><\/td>\r\n <\/tr>\r\n <tr>\r\n <td><textarea name=\"particularBuilding[]\"><\/textarea><\/td>\r\n <td><input type=\"text\" name=\"dateConstruction[]\"><\/td>\r\n <td><input type=\"text\" name=\"nameContractor[]\"><\/td>\r\n <td><input type=\"text\" name=\"originalCostPrice[]\"><\/td>\r\n <td><input type=\"text\" name=\"valueFireDestruction[]\"><\/td>\r\n <td><input type=\"text\" name=\"presentReinstatementCost[]\"><\/td>\r\n <td><input type=\"text\" name=\"amountClaimed[]\"><\/td>\r\n <\/tr>\r\n <tr>\r\n <td><textarea name=\"particularBuilding[]\"><\/textarea><\/td>\r\n <td><input type=\"text\" name=\"dateConstruction[]\"><\/td>\r\n <td><input type=\"text\" name=\"nameContractor[]\"><\/td>\r\n <td><input type=\"text\" name=\"originalCostPrice[]\"><\/td>\r\n <td><input type=\"text\" name=\"valueFireDestruction[]\"><\/td>\r\n <td><input type=\"text\" name=\"presentReinstatementCost[]\"><\/td>\r\n <td><input type=\"text\" name=\"amountClaimed[]\"><\/td>\r\n <\/tr>\r\n <tr>\r\n <td><textarea name=\"particularBuilding[]\"><\/textarea><\/td>\r\n <td><input type=\"text\" name=\"dateConstruction[]\"><\/td>\r\n <td><input type=\"text\" name=\"nameContractor[]\"><\/td>\r\n <td><input type=\"text\" name=\"originalCostPrice[]\"><\/td>\r\n <td><input type=\"text\" name=\"valueFireDestruction[]\"><\/td>\r\n <td><input type=\"text\" name=\"presentReinstatementCost[]\"><\/td>\r\n <td><input type=\"text\" name=\"amountClaimed[]\"><\/td>\r\n <\/tr>\r\n <tr>\r\n <td><textarea name=\"particularBuilding[]\"><\/textarea><\/td>\r\n <td><input type=\"text\" name=\"dateConstruction[]\"><\/td>\r\n <td><input type=\"text\" name=\"nameContractor[]\"><\/td>\r\n <td><input type=\"text\" name=\"originalCostPrice[]\"><\/td>\r\n <td><input type=\"text\" name=\"valueFireDestruction[]\"><\/td>\r\n <td><input type=\"text\" name=\"presentReinstatementCost[]\"><\/td>\r\n <td><input type=\"text\" name=\"amountClaimed[]\"><\/td>\r\n <\/tr>\r\n <\/tbody>\r\n <\/table>\r\n\r\n <div class=\"form-group\">\r\n <label for=\"totalAmountClaimed\">Total Amount Claimed<\/label>\r\n <input type=\"text\" id=\"totalAmountClaimed\" name=\"totalAmountClaimed\">\r\n <\/div>\r\n\r\n <p class=\"notice\">SPECIAL NOTICE : Going by the policy terms and conditions, the claim request could be rendered\r\n void if any claim is found to be fraudulent or intentionally exaggerated or if any false statement or declaration\r\n is made. It is therefore important that this form should be completed with great care.<\/p>\r\n\r\n <p>I \/ We declared the foregoing particulars to be true representation of the incident that happened.<\/p>\r\n\r\n <div class=\"form-group\">\r\n <label for=\"signatureOfInsured\">Signature of the insured:<\/label>\r\n <input type=\"file\" id=\"signatureOfInsured\" name=\"signatureOfInsured\" required>\r\n <span id=\"signatureOfInsuredError\" class=\"error\"><\/span>\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label for=\"date\">Date:<\/label>\r\n <input type=\"text\" id=\"date\" name=\"date\" required>\r\n <span id=\"dateError\" class=\"error\"><\/span>\r\n <\/div>\r\n\r\n <p class=\"notice\">*(If corporate, give status of the signatory) *<\/p>\r\n\r\n <button type=\"submit\">Submit Claim<\/button>\r\n <\/form>\r\n <\/div>\r\n\r\n <script>\r\n function validateForm() {\r\n let isValid = true;\r\n\r\n \/\/ Basic validation - improve as needed\r\n isValid = validateField(\"policyNumber\", \"Policy Number is required\") && isValid;\r\n isValid = validateField(\"nameOfInsured\", \"Name of Insured is required\") && isValid;\r\n isValid = validateField(\"address\", \"Address is required\") && isValid;\r\n isValid = validateField(\"occupation\", \"Occupation is required\") && isValid;\r\n isValid = validateField(\"emailAddress\", \"Valid Email is required\", \"email\") && isValid;\r\n isValid = validateField(\"inceptionDate\", \"Inception Date is required\") && isValid;\r\n isValid = validateField(\"situationOfPremises\", \"Situation of Premises is required\") && isValid;\r\n isValid = validateField(\"proximateCauseOfLoss\", \"Proximate Cause of Loss is required\") && isValid;\r\n isValid = validateField(\"dateOfIncident\", \"Date of Incident is required\") && isValid;\r\n isValid = validateField(\"detailsOfIncident\", \"Details of Incident are required\") && isValid;\r\n isValid = validateField(\"soleOwner\", \"Sole Owner selection is required\") && isValid;\r\n isValid = validateField(\"responsibleForRepair\", \"Responsible for Repair selection is required\") && isValid;\r\n isValid = validateField(\"salvageableItems\", \"Salvageable Items selection is required\") && isValid;\r\n isValid = validateField(\"signatureOfInsured\", \"Signature is required\") && isValid;\r\n isValid = validateField(\"date\", \"Date is required\") && isValid;\r\n\r\n\r\n return isValid;\r\n }\r\n\r\n function validateField(fieldId, errorMessage, type = \"text\") {\r\n const field = document.getElementById(fieldId);\r\n const errorSpan = document.getElementById(fieldId + \"Error\");\r\n\r\n if (!field.value.trim()) {\r\n errorSpan.textContent = errorMessage;\r\n return false;\r\n }\r\n\r\n if (type === \"email\" && !isValidEmail(field.value)) {\r\n errorSpan.textContent = \"Invalid email format\";\r\n return false;\r\n }\r\n\r\n errorSpan.textContent = \"\"; \/\/ Clear any previous error\r\n return true;\r\n }\r\n\r\n function isValidEmail(email) {\r\n const emailRegex = \/^[^\\s@]+@[^\\s@]+\\.[^\\s@]+$\/;\r\n return emailRegex.test(email);\r\n }\r\n <\/script>\r\n<\/body>\r\n\r\n<\/html>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-798c524 elementor-section-boxed elementor-section-height-default elementor-section-height-default wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no\" data-id=\"798c524\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"aux-parallax-section elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-bbbe4f9\" data-id=\"bbbe4f9\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-396705a elementor-widget elementor-widget-html\" data-id=\"396705a\" data-element_type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<!DOCTYPE html>\r\n<html lang=\"en\">\r\n\r\n<head>\r\n <meta charset=\"UTF-8\">\r\n <meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\">\r\n <title>Motor Accident Claim Form<\/title>\r\n <style>\r\n \/* Enhanced Styling *\/\r\n body {\r\n font-family: Arial, sans-serif;\r\n line-height: 1.6;\r\n margin: 20px;\r\n background-color: #f4f4f4;\r\n }\r\n\r\n .container {\r\n max-width: 800px;\r\n margin: 0 auto;\r\n background-color: #fff;\r\n padding: 20px;\r\n border-radius: 8px;\r\n box-shadow: 0 0 10px rgba(0, 0, 0, 0.1);\r\n }\r\n\r\n h1 {\r\n text-align: center;\r\n color: #333;\r\n }\r\n\r\n .form-group {\r\n margin-bottom: 15px;\r\n }\r\n\r\n label {\r\n display: block;\r\n margin-bottom: 5px;\r\n font-weight: bold;\r\n color: #555;\r\n }\r\n\r\n input[type=\"text\"],\r\n input[type=\"email\"],\r\n input[type=\"tel\"],\r\n textarea,\r\n input[type=\"file\"], \/* Added file input styling *\/\r\n select {\r\n width: 100%;\r\n padding: 10px;\r\n border: 1px solid #ddd;\r\n border-radius: 4px;\r\n box-sizing: border-box;\r\n }\r\n\r\n textarea {\r\n resize: vertical;\r\n min-height: 100px;\r\n }\r\n\r\n table {\r\n width: 100%;\r\n border-collapse: collapse;\r\n margin-top: 20px;\r\n }\r\n\r\n table,\r\n th,\r\n td {\r\n border: 1px solid #ddd;\r\n padding: 10px;\r\n text-align: left;\r\n }\r\n\r\n th {\r\n background-color: #f9f9f9;\r\n font-weight: bold;\r\n color: #333;\r\n }\r\n\r\n .notice {\r\n font-style: italic;\r\n color: #777;\r\n margin-top: 10px;\r\n }\r\n\r\n button[type=\"submit\"] {\r\n background-color: #4CAF50;\r\n color: white;\r\n padding: 12px 20px;\r\n border: none;\r\n border-radius: 4px;\r\n cursor: pointer;\r\n font-size: 16px;\r\n }\r\n\r\n button[type=\"submit\"]:hover {\r\n background-color: #45a049;\r\n }\r\n\r\n .error {\r\n color: red;\r\n font-size: 0.8em;\r\n margin-top: 5px;\r\n }\r\n <\/style>\r\n<\/head>\r\n\r\n<body>\r\n <div class=\"container\">\r\n <h1>MOTOR ACCIDENT CLAIM FORM<\/h1>\r\n <form action=\"submit-motor-claim.php\" method=\"POST\" enctype=\"multipart\/form-data\" onsubmit=\"return validateForm()\">\r\n <div class=\"form-group\">\r\n <label for=\"policyNumber\">Policy Number<\/label>\r\n <input type=\"text\" id=\"policyNumber\" name=\"policyNumber\" required>\r\n <span id=\"policyNumberError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"claimNumber\">Claim Number<\/label>\r\n <input type=\"text\" id=\"claimNumber\" name=\"claimNumber\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"nameOfInsured\">Name of Insured<\/label>\r\n <input type=\"text\" id=\"nameOfInsured\" name=\"nameOfInsured\" required>\r\n <span id=\"nameOfInsuredError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"address\">Address<\/label>\r\n <textarea id=\"address\" name=\"address\" required><\/textarea>\r\n <span id=\"addressError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"occupation\">Occupation<\/label>\r\n <input type=\"text\" id=\"occupation\" name=\"occupation\" required>\r\n <span id=\"occupationError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"telephoneNumber\">Telephone Number<\/label>\r\n <input type=\"tel\" id=\"telephoneNumber\" name=\"telephoneNumber\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"emailAddress\">Email Address<\/label>\r\n <input type=\"email\" id=\"emailAddress\" name=\"emailAddress\" required>\r\n <span id=\"emailAddressError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"inceptionDate\">Inception Date<\/label>\r\n <input type=\"text\" id=\"inceptionDate\" name=\"inceptionDate\" required>\r\n <span id=\"inceptionDateError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"branch\">Branch<\/label>\r\n <input type=\"text\" id=\"branch\" name=\"branch\">\r\n <\/div>\r\n\r\n <h2>Insured Particulars (Vehicle)<\/h2>\r\n <table>\r\n <thead>\r\n <tr>\r\n <th>Make<\/th>\r\n <th>Reg. No.<\/th>\r\n <th>C.C<\/th>\r\n <th>Year of Make<\/th>\r\n <th>Engine No.<\/th>\r\n <th>Chassis No.<\/th>\r\n <th>Value of the Vehicle<\/th>\r\n <th>Purpose of Use<\/th>\r\n <\/tr>\r\n <\/thead>\r\n <tbody>\r\n <tr>\r\n <td><input type=\"text\" name=\"make\"><\/td>\r\n <td><input type=\"text\" name=\"regNo\"><\/td>\r\n <td><input type=\"text\" name=\"cC\"><\/td>\r\n <td><input type=\"text\" name=\"yearOfMake\"><\/td>\r\n <td><input type=\"text\" name=\"engineNo\"><\/td>\r\n <td><input type=\"text\" name=\"chassisNo\"><\/td>\r\n <td><input type=\"text\" name=\"valueOfVehicle\"><\/td>\r\n <td><input type=\"text\" name=\"purposeOfUse\"><\/td>\r\n <\/tr>\r\n <\/tbody>\r\n <\/table>\r\n\r\n <h2>Driver at the time of Accident<\/h2>\r\n <div class=\"form-group\">\r\n <label for=\"driverName\">Name<\/label>\r\n <input type=\"text\" id=\"driverName\" name=\"driverName\" required>\r\n <span id=\"driverNameError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"driverAge\">Age<\/label>\r\n <input type=\"number\" id=\"driverAge\" name=\"driverAge\" required>\r\n <span id=\"driverAgeError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"driverAddress\">Address<\/label>\r\n <textarea id=\"driverAddress\" name=\"driverAddress\" required><\/textarea>\r\n <span id=\"driverAddressError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"driversLicenseInForce\">Is Driver\u2019s License in force<\/label>\r\n <select id=\"driversLicenseInForce\" name=\"driversLicenseInForce\" required>\r\n <option value=\"\">-- Select --<\/option>\r\n <option value=\"yes\">Yes<\/option>\r\n <option value=\"no\">No<\/option>\r\n <\/select>\r\n <span id=\"driversLicenseInForceError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"driversLicenseCategory\">If yes, which category<\/label>\r\n <input type=\"text\" id=\"driversLicenseCategory\" name=\"driversLicenseCategory\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"driversLicenseNumber\">Driving License Number<\/label>\r\n <input type=\"text\" id=\"driversLicenseNumber\" name=\"driversLicenseNumber\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"driversLicenseEndorsed\">Has it been endorsed<\/label>\r\n <select id=\"driversLicenseEndorsed\" name=\"driversLicenseEndorsed\" required>\r\n <option value=\"\">-- Select --<\/option>\r\n <option value=\"yes\">Yes<\/option>\r\n <option value=\"no\">No<\/option>\r\n <\/select>\r\n <span id=\"driversLicenseEndorsedError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"driversLicenseIssueDate\">Date of Issuance<\/label>\r\n <input type=\"text\" id=\"driversLicenseIssueDate\" name=\"driversLicenseIssueDate\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"driversLicenseIssuePlace\">Place of Issuance<\/label>\r\n <input type=\"text\" id=\"driversLicenseIssuePlace\" name=\"driversLicenseIssuePlace\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"driversLicenseExpiryDate\">Date of Expiry<\/label>\r\n <input type=\"text\" id=\"driversLicenseExpiryDate\" name=\"driversLicenseExpiryDate\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"driversLicenseLearnersPermit\">Is it a Learner\u2019s permit<\/label>\r\n <select id=\"driversLicenseLearnersPermit\" name=\"driversLicenseLearnersPermit\" required>\r\n <option value=\"\">-- Select --<\/option>\r\n <option value=\"yes\">Yes<\/option>\r\n <option value=\"no\">No<\/option>\r\n <\/select>\r\n <span id=\"driversLicenseLearnersPermitError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"driversLicenseLearnersPermitNumber\">If so, state number and Period<\/label>\r\n <input type=\"text\" id=\"driversLicenseLearnersPermitNumber\" name=\"driversLicenseLearnersPermitNumber\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"driverRelationshipToInsured\">Relationship of driver to the insured<\/label>\r\n <input type=\"text\" id=\"driverRelationshipToInsured\" name=\"driverRelationshipToInsured\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"driverPaidDriverForHowLong\">If paid driver, for how long<\/label>\r\n <input type=\"text\" id=\"driverPaidDriverForHowLong\" name=\"driverPaidDriverForHowLong\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"driverOwnsVehicle\">Does the driver own a vehicle<\/label>\r\n <select id=\"driverOwnsVehicle\" name=\"driverOwnsVehicle\" required>\r\n <option value=\"\">-- Select --<\/option>\r\n <option value=\"yes\">Yes<\/option>\r\n <option value=\"no\">No<\/option>\r\n <\/select>\r\n <span id=\"driverOwnsVehicleError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"driverInsurerNameAddress\">If so, name and address of the insurer<\/label>\r\n <input type=\"text\" id=\"driverInsurerNameAddress\" name=\"driverInsurerNameAddress\">\r\n <\/div>\r\n\r\n <h2>Information on Accident<\/h2>\r\n <div class=\"form-group\">\r\n <label for=\"accidentDate\">Date<\/label>\r\n <input type=\"text\" id=\"accidentDate\" name=\"accidentDate\" required>\r\n <span id=\"accidentDateError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"accidentTime\">Time<\/label>\r\n <input type=\"text\" id=\"accidentTime\" name=\"accidentTime\" required>\r\n <span id=\"accidentTimeError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"accidentExactLocation\">Exact Location<\/label>\r\n <textarea id=\"accidentExactLocation\" name=\"accidentExactLocation\" required><\/textarea>\r\n <span id=\"accidentExactLocationError\" class=\"error\"><\/span>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"accidentRoadCondition\">Road Condition<\/label>\r\n <input type=\"text\" id=\"accidentRoadCondition\" name=\"accidentRoadCondition\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"accidentWeatherCondition\">Weather Condition<\/label>\r\n <input type=\"text\" id=\"accidentWeatherCondition\" name=\"accidentWeatherCondition\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"accidentVehicleSpeed\">Speed of the Vehicle<\/label>\r\n <input type=\"text\" id=\"accidentVehicleSpeed\" name=\"accidentVehicleSpeed\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"accidentBrakeCondition\">Brake Condition<\/label>\r\n <input type=\"text\" id=\"accidentBrakeCondition\" name=\"accidentBrakeCondition\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"accidentCollisionDirection\">Direction of Collision if applicable<\/label>\r\n <input type=\"text\" id=\"accidentCollisionDirection\" name=\"accidentCollisionDirection\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"accidentPoliceStationAddress\">Address of Police Station where Accident was reported<\/label>\r\n <textarea id=\"accidentPoliceStationAddress\" name=\"accidentPoliceStationAddress\"><\/textarea>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"accidentInsuredVehicleOccupants\">Number of Person(s) in: (i). Insured\u2019s vehicle<\/label>\r\n <input type=\"number\" id=\"accidentInsuredVehicleOccupants\" name=\"accidentInsuredVehicleOccupants\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"accidentThirdPartyVehicleOccupants\"> (ii). Third party\u2019s vehicle<\/label>\r\n <input type=\"number\" id=\"accidentThirdPartyVehicleOccupants\" name=\"accidentThirdPartyVehicleOccupants\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"accidentInsuredInjury\">Any injury sustained by the insured<\/label>\r\n <textarea id=\"accidentInsuredInjury\" name=\"accidentInsuredInjury\"><\/textarea>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"accidentDescription\">Full Description of Accident<\/label>\r\n <textarea id=\"accidentDescription\" name=\"accidentDescription\" required><\/textarea>\r\n <span id=\"accidentDescriptionError\" class=\"error\"><\/span>\r\n <\/div>\r\n\r\n <h2>Witness<\/h2>\r\n <div class=\"form-group\">\r\n <label for=\"witness1NameAddress\">Name and Address 1.<\/label>\r\n <textarea id=\"witness1NameAddress\" name=\"witness1NameAddress\"><\/textarea>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"witness2NameAddress\">Name and Address 2.<\/label>\r\n <textarea id=\"witness2NameAddress\" name=\"witness2NameAddress\"><\/textarea>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"witness3NameAddress\">Name and Address 3.<\/label>\r\n <textarea id=\"witness3NameAddress\" name=\"witness3NameAddress\"><\/textarea>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"witness4NameAddress\">Name and Address 4.<\/label>\r\n <textarea id=\"witness4NameAddress\" name=\"witness4NameAddress\"><\/textarea>\r\n <\/div>\r\n\r\n <h2>Details of damaged parts<\/h2>\r\n <div class=\"form-group\">\r\n <label for=\"damagedPartsDetails\"> <\/label>\r\n <textarea id=\"damagedPartsDetails\" name=\"damagedPartsDetails\" required><\/textarea>\r\n <span id=\"damagedPartsDetailsError\" class=\"error\"><\/span>\r\n <\/div>\r\n\r\n <h2>Rough Estimate of Repairs<\/h2>\r\n <div class=\"form-group\">\r\n <label for=\"repairsEstimate\"> <\/label>\r\n <textarea id=\"repairsEstimate\" name=\"repairsEstimate\" required><\/textarea>\r\n <span id=\"repairsEstimateError\" class=\"error\"><\/span>\r\n <\/div>\r\n\r\n <h2>Present Location of Vehicle<\/h2>\r\n <div class=\"form-group\">\r\n <label for=\"vehicleLocation\"> <\/label>\r\n <textarea id=\"vehicleLocation\" name=\"vehicleLocation\" required><\/textarea>\r\n <span id=\"vehicleLocationError\" class=\"error\"><\/span>\r\n <\/div>\r\n\r\n <h2>Repairer\u2019s Name and Address<\/h2>\r\n <div class=\"form-group\">\r\n <label for=\"repairerNameAddress\"> <\/label>\r\n <textarea id=\"repairerNameAddress\" name=\"repairerNameAddress\"><\/textarea>\r\n <\/div>\r\n\r\n <h2>Details of Third Party<\/h2>\r\n <div class=\"form-group\">\r\n <label for=\"thirdPartyName\">Name(s):<\/label>\r\n <input type=\"text\" id=\"thirdPartyName\" name=\"thirdPartyName\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"thirdPartyAddress\">Address:<\/label>\r\n <textarea id=\"thirdPartyAddress\" name=\"thirdPartyAddress\"><\/textarea>\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"thirdPartyPropertyNature\">Nature of Property:<\/label>\r\n <input type=\"text\" id=\"thirdPartyPropertyNature\" name=\"thirdPartyPropertyNature\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label for=\"thirdPartyVehicleDetails\">If vehicle; Make, model, Reg No. and year of make<\/label>\r\n <textarea id=\"thirdPartyVehicleDetails\" name=\"thirdPartyVehicleDetails\"><\/textarea>\r\n <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>CLAIM FORM Motor Claim Form\u00a0 Fire Claim Form All Risk Claim Form \u00a0 All Risk Claim Form ALL RISK CLAIM FORM Policy Number Claim Number Insured\u2019s Name in full Address Occupation Telephone Number Email Address Inception date \/ Renewal date Nature of Loss Describe the full circumstances of the loss, stating the date and time Do you suspect any person in connection therewith? The date police was advised and the address of the station What other steps have been taken to recover the property? Please give full details Are there any other insurances against this loss? PARTICULARS OF CLAIM No. of Article Full Description Name and address of seller Date of purchase Cost Paid Amount of Claim Special Notice: By the conditions, the policy is rendered void if any claim be fraudulent or intentionally exaggerated or if any false statement or declaration be made in support of it. It is therefore important that this form be filled with great care. I hereby declare that the within mentioned money \/ property (ies) belonging to me and insured under the said policy was lost, damaged or stolen in the circumstances stated and that in consequence thereof a claim is hereby being made for the sums severally stated within. Witness Signature Date NB: This statement of claim should be completed and forwarded immediately to the Company. The insured must at once take every practical and reasonable step that may lead to the recovery of money\/property(ies). The police must be advised immediately and any suspicious deal as to the parties implicated must be communicated to the company without delay. Should any of the insured\u2019s money \/ property which is the subject of this claim be recovered either before or after the indemnity has been provided under the within named policy, the Company must be notified immediately. Submit Claim Fire \/ Material Damage Claim Form FIRE \/ MATERIAL DAMAGE CLAIM FORM Policy Number Claim Number Name of Insured Address Occupation Telephone Number Email Address Inception Date Branch or Agent to whom premium was paid Trade \/ Occupation (state all, if more than one) Situation of the Premises affected \/ damaged Proximate Cause of loss \/ incident Date of incident \/ loss Details of how the incident occurred Have you ever lodged or reported a claim or claimed against any insurer on the risk insured? If so, give details: Are you the sole owner of the destroyed \/ damaged property? — Select —YesNo If no, state the name(s) of other interested parties and the nature of their interest: In respect of damage to buildings or landlord\u2019s fixtures (including internal decoration), are you responsible for repair of such damage under the terms of a tenancy agreement? — Select —YesNo Was there at the time of the occurrence of loss any other existing insurance effected by you or any other person(s) on the property for which this claim is being made? If so, please give details In view of the nature of loss \/ incident, is there going to be salvageable items? — Select —YesNo If yes, is the insured or property owner interested in keeping same? — Select —YesNo Any damaged property(ies) or items should not be disposed off without intimating the insurer or getting insurer\u2019s approval \/ permission. Details of claim and estimation Particular of each building or factory or article in respect of which this claim is made Date of construction or purchased or received Name of the Contractor\/ from whom purchased or donated Original cost price Value at the time of fire destruction after given allowance for aging, wear and tear Present reinstatement cost Amount claimed after given allowance for value of salvage or cost of repairs Total Amount Claimed SPECIAL NOTICE : Going by the policy terms and conditions, the claim request could be rendered void if any claim is found to be fraudulent or intentionally exaggerated or if any false statement or declaration is made. It is therefore important that this form should be completed with great care. I \/ We declared the foregoing particulars to be true representation of the incident that happened. Signature of the insured: Date: *(If corporate, give status of the signatory) * Submit Claim Motor Accident Claim Form MOTOR ACCIDENT CLAIM FORM Policy Number Claim Number Name of Insured Address Occupation Telephone Number Email Address Inception Date Branch Insured Particulars (Vehicle) Make Reg. No. C.C Year of Make Engine No. Chassis No. Value of the Vehicle Purpose of Use Driver at the time of Accident Name Age Address Is Driver\u2019s License in force — Select —YesNo If yes, which category Driving License Number Has it been endorsed — Select —YesNo Date of Issuance Place of Issuance Date of Expiry Is it a Learner\u2019s permit — Select —YesNo If so, state number and Period Relationship of driver to the insured If paid driver, for how long Does the driver own a vehicle — Select —YesNo If so, name and address of the insurer Information on Accident Date Time Exact Location Road Condition Weather Condition Speed of the Vehicle Brake Condition Direction of Collision if applicable Address of Police Station where Accident was reported Number of Person(s) in: (i). Insured\u2019s vehicle (ii). Third party\u2019s vehicle Any injury sustained by the insured Full Description of Accident Witness Name and Address 1. Name and Address 2. Name and Address 3. Name and Address 4. Details of damaged parts Rough Estimate of Repairs Present Location of Vehicle Repairer\u2019s Name and Address Details of Third Party Name(s): Address: Nature of Property: If vehicle; Make, model, Reg No. and year of make<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"templates\/page-builder-content.php","meta":{"_eb_attr":"","footnotes":""},"class_list":["post-1887","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"http:\/\/ceiil.ng\/index.php\/wp-json\/wp\/v2\/pages\/1887","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/ceiil.ng\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"http:\/\/ceiil.ng\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"http:\/\/ceiil.ng\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/ceiil.ng\/index.php\/wp-json\/wp\/v2\/comments?post=1887"}],"version-history":[{"count":29,"href":"http:\/\/ceiil.ng\/index.php\/wp-json\/wp\/v2\/pages\/1887\/revisions"}],"predecessor-version":[{"id":2080,"href":"http:\/\/ceiil.ng\/index.php\/wp-json\/wp\/v2\/pages\/1887\/revisions\/2080"}],"wp:attachment":[{"href":"http:\/\/ceiil.ng\/index.php\/wp-json\/wp\/v2\/media?parent=1887"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}