Motor Insurance Claim Form

Personal information provided on your application form is protected and used in accordance with the provisions of the Data Protection Act.

The following procedure applies only to GasanMamo Insurance Ltd clients. If you are not insured with GasanMamo Insurance Ltd you may contact us on insurance@gasanmamo.com and make your enquiry.

Reporting an incident
In the event of an incident, which is covered by your Motor Insurance Policy issued by GasanMamo Insurance Ltd, you are required to inform us of it as soon as possible. You may do this by completing the on-line claim form. When you have completed the required fields, click on SEND and this will be automatically forwarded to us. We would then confirm receipt of your e-mail by return e-mail providing you with a reference number and advising you how much your excess is. We will also mail you a printed version of the claim form which you would be required to sign and return to us by mail together with the payment of your excess and some other documents detailed below. There may be cases where it will be necessary for you to visit our claims department in person.

Documents required
1. A completed claim form
2. Settlement of Excess
3. A copy of your Identity Card
4. A copy of the driver’s driving licence
5. when applicable, the completed front to rear form

We will contact you if we require any other documents or information. If you possess a scanner you may also send us scanned copies of these documents via email (insurance@gasanmamo.com) after you have submitted the on-line claim form as this will speed up the process.

Excess
Please remember that very often you will be required to pay the policy excess before the claims process can commence. Since the amount of the excess can vary, as this depends on the circumstances of the case, we will notify you of the amount payable. The excess can be paid at our Head Office or any of our Branch offices in cash, credit or debit card. You may also send us a cheque payable to GasanMamo Insurance Ltd. The excess can also be settled through your internet banking.

Processing of claim
Upon receipt of the completed internet claim form, we will start processing your claim on a without prejudice basis. However, if all the above required documents are received we will be in a position to proceed towards settling your claim.

Front to Rear Collisions
When the collision is a front to rear one, we would also require receiving a copy of the completed front-to-rear form signed by the parties involved.

Wardens Reports
If the accident has been attended to by the local wardens, a copy of the accident report will be sent to us automatically. You do not need to take any action in such cases. Upon receipt of the wardens report we will contact you in order to proceed with whatever action is necessary.

Police Report
We would remind you that you are also required by law and by the policy conditions to report to the Police the following incidents:
· Acts of vandalism or malicious damage
· Damage to public property
· Injuries incurred as a result of a motor accident
· Hit and run accidents
· Theft or attempted theft
· Damages arising from fire

In such cases we would need a copy of the Police Report before we process your claim. We will obtain a copy of this ourselves, however in order to speed up the matter we would recomend to collect a copy of the Police report yourself and send it to us.

You may view the policy General Conditions should you require seeing the full extent of your cover by using the following links depending on your type of vehicle:

Private Car Policy

Commercial Vehicle Policy

Motorcycle Policy

Motor Internet Claim Form

Fields marked with a * need to be completed

Accident Date*	(Format: DD/MM/YYYY)

Accident Time*	Hour : Minute

Policy No*

Regn No*

OWNER

Name*

ID No*

Address*

Tel No*

Mob*

E-mail*

DRIVER

Is driver same as policyholder?

Yes

If “No” then complete driver details.” If yes the fields concerning the driver need not be completed.

Name

ID No

Address

Tel No

Mob

E-mail

Driving Licence No

Group

Relationship with policyholder

ACCIDENT

Locality*

Street Name

Reported to*

Wardens

Police

Front to Rear Form

Description of Accident*

Police Station

WITNESS

Has anyone seen the accident?

Yes

Name

Address

ID No

Tel No

INJURIES

Was anyone injured in the accident?

Yes

Name

ID No

Address

Tel No

Nature of Injury

Taken to Hospital/Clinic

Yes No

THIRD PARTY DETAILS (Other cars involved in the accident)

Were there any other cars involved in the accident?

Yes

	Car 1	Car 2	Car 3
Owner of other car

Regn No

Make/Model

Insurance

VAT No

ID No

Address

Tel

E-mail

Cover

Driver ID No

Name

Address

Tel

REPAIRS

If your vehicle is comprehensively insured please indicate hereunder where you wish to repair your vehicle. We will contact you to fix an appointment with our surveyor upon recipt of this internet claim form at the approved Malta Standards Authority(MSA) repairer of your choice.

Approved Repairer

Tel No

Address

Damage

Please tick one or more

Front

Rear

Left

Right

Underneath

Roof

All over

Mechanical

RESPONSIBILITY FOR THE ACCIDENT

In my opinion

Please tick one

I am at fault

We are both at fault

Other car is at fault

Not sure

DATA PROTECTION NOTICE

To the extent that the information supplied by you, whether orally or in writing, constitutes personal data, including sensitive data within the provisions of the Data Protection Act, you consent to the processing of such data for purposes of administering your proposal for insurance, your Policy, underwriting, handling of claims and also for the purposes of detecting, preventing and suppressing fraud and of keeping statistics. We may be required to collect further information from our sub-agents, other insurance companies, insurance intermediaries or insurance associations.

In addition, we may pass some or all of the information to other insurance companies, or insurance associations for underwriting and claims handling purposes and also for the purposes of detecting, preventing and suppressing fraud and of keeping statistics. This also helps us to check the information provided. When we deal with your request for insurance, we may search this information. When you tell us about an incident which may or may not give rise to a claim, we will pass information relating to it to the Malta Insurance Association.

We or other companies within our group would like, on occasion, to keep you informed of our products and services, by mail, fax, e-mail or other electronic means. Please inform us in writing if you do not wish to receive this information or if you wish to receive such information solely from GasanMamo Insurance Ltd. Moreover, we hereby ask you whether you wish to receive direct marketing information from us by e-mail to your e-mail address provided above.

You have the right to request access to, and rectification of, your personal data held by us by directing your request in writing signed by yourself to the Data Protection Officer, GasanMamo Insurance Ltd., Msida Road, Gzira GZR 1405.

DECLARATION

All communications relating to the accident must be forwarded immediately unanswered to the Company.

I/We declare that I have read this completed form and that the information given here is true and correct to the best of my/our knowledge/belief.

Owner

I Agree*