Pan Oceanic Insurance Brokers

P.O. Box 3912 DAR ES SALAAM, TANZANIA Tel: +255 22 2132540/45 Fax: +255 22 2132514

Details of Policy Holder
Name:
Mailing Address:
City:
Business Phone:
Mobile Phone:
Business Fax:
E-mail Address:
Cover Note No.
Period of Insurance:	to
For Motor Accidents Only
Vehicle Make:
Model:
Registration Number:
Year 1st Registered:
C.C. :
Tonnage:
Driver's Name:
Age:
Experience:
Type of License:
Circumstances of Accident (All Types of Claims)
Date:	Time: AM PM
Place: Street or Road	Town:
Police Station Reported
Please Explain Details of what exactly happened:
Contact Person Name:

Pan Oceanic Insurance Brokers P.O. Box 3912 Dar Es Salaam, Tanzania Tel: +255 22 2132540/45 Fax: +255 22 2132514 Email: info@panoceanictz.com