Underwriting & Accounts Verification Form

Please complete relevant section of the form, attach Pre-Risk survey Report and
return to the Claims Division.
I. To be completed by cl aims
Insured YISHAK YILMA
Policy No GU/40/1021/2019/01356
Plate No. 2-A70489AA
Date of Accident 12/12/2023
Nature of Accident COLLISION
Chassis No. SCP10-0422816
Engine No. 1SZ-1074248
Claim No. GC/40/1021/2023/00147
Claims

SOLOMON
AREGA
II. To be completed by Underwriting
1. Insured :

2. Plate No. :

3. Model :

4. Chassis No. :

5. Engine No. :

6. Year of Make :

7. Policy No. :

8. Purpose of vehicle : __________________________________________

9. Type of Cover :

10. Expired Period of Insurance (if any): From To

11. New/Renewed Period of Insurance: From To

12. Sum Insured E.Br. :

13. Excess E.Br. :

14. Expired Third party Period of Insurance (if any): From To

15. Third party Period of Insurance (if any): From__ _____ _ To___

16. Third Party Limits : __________________________________________

Existing Comprehensive New Policies
Emergency Medical Expense
Bodily Injury
Death
 Property Damage
17. Extension : 1. PAB
2. BSG
3. Others
18. Bank or Other Interest (if any):

19. Previous Claim Record :

20. Remark on pre risk survey & Attach: __________________________________________

21. If pre-risk report is not attached, please specify your reason:

22. Outstanding Premium :

Underwriting

III. To be Completed by Finance

1. Outstanding Premium :
Finance