MAPFRE Middlesea Motor insurance Claim form

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My Ins Policy No.
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Motor Insurance Claim Form
Intermediary's Email*
Policy Number*
Vehicle Registration Number
Policy holder details
I.D. card number
Full Name

First NameLast Name
House Name / Number
Street Name / Number
Locality
Post Code
Date of birth

DayMonthYear
Date
Telephone/Mobile*
Email
example@example.com
Business Or Occupation

BusinessOccupation
VAT reg. number
VAT status
Enter Your Occupation
Is driver policy holder?

YesNo

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Driver Details
I.D. card number
Full Name

First NameLast Name
House Name / Number
Street Name / Number
Locality
Post Code
Date of birth

DayMonthYear
Date
Telephone/Mobile
Email
example@example.com
Occupation
Relationship with policy holder
Was driver using vehicle with policy holder's permission

YesNo

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Police Details
Accident was reported to:*

WardensPoliceFront To RearOther
Report Number*
Kindly attach a copy of the Front-to-Rear form/s

Cancelof

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Witness Details
Witness

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Document/s Upload
Please upload a copy of the driver’s driving license (front & back)

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Should you have any further documentation which may assist us in handling your claim, please attach a copy (for example: photos/video/witness statements/ etc.)

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Terms & Conditions
Signature of Policyholder*

Clear
Signature of Driver*

Clear
Tick this box to continue. Please read carefully.*

I/We hereby declarethat the above information and statements are, to the best of my/our knowledgeand belief, correct and complete. I/We confirm to have read the answers andthat they are correct and that such person completing this form on my/our dictationor instruction for this purpose will be regarded as my/our agent.
After you submit the form you will be shown a copy of the information you have sent and you should also receive an email confirmation.

If either of these doesn't happen, please call us on: +356 21 246 262
DATA PROTECTION

MAPFRE Middlesea p.l.c. is legally bound to follow the provisions of the Data Protection Act, 2018. If you require any further information about how MAPFRE Middlesea Plc processes your personal data, please follow this link https://www.mapfre.com.mt/privacy-policy.
MAPFRE Middlesea p.l.c. (C-5553) is authorised by the Malta Financial Services Authority (MFSA) to carry on both Long Term and General Business under the Insurance Business Act. MAPFRE Middlesea p.l.c. is regulated by the MFSA.
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Motor Insurance Claim Form

Policy holder details

Driver Details

Accident Details

Third Party Details

Police Details

Witness Details

Document/s Upload

Terms & Conditions