Persons in the car during accident
In case of bodily injured
Information related to third party 1
Information related to third party 2
Information related to third party 3
Damages of third party
I declare that I have answered all above questions as to the best of my knowledge and I pledge to provide Capital Insurance & Reinsurance Co. sal all possible assistance in relation to this accident. I also declare that I do not hold any other insurance policy that will allow me to submit any claim in relation to this accident.