INSURANCE INDUSTRY COMPENSATION FUND
Hit and Run Claim Form
Instructions
Please click
here
to view the list of instructions before applying online.
*
are mandatory fields and need to be filled
Victim
Title
-- select an option --
Mr
Mrs
Ms
Surname
*
Othername
*
National ID Number
*
Address
*
Phone Number
*
Email
*
Occupation
*
Claimant
Title
-- select an option --
Mr
Mrs
Ms
Surname
*
Othername
*
National ID Number
*
Address
*
Phone Number
*
Email
*
Occupation
*
Details of accident
Date and Time of accident
*
Location of accident
*
Description of accident
*
Details of police involvement
Date and police station where the accident was reported
*
Police OB number
*
Details of injury sustained
Provide a brief on the injuries sustained during the accident
*
Hospital/Clinic attended and patient file number
*
Number of days admitted as inpatient
*
