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MOTOR ACCIDENT CLAIM FORM

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MOTOR ACCIDENT CLAIM FORM Powered By Docstoc
					                                                              LOGO
                                                          Registration No.
                                                      Postal & Physical Address
                                                           Contact Details




                                               MOTOR ACCIDENT CLAIM FORM


Every question must be answered fully (can be answered in English or Afrikaans), the abbreviation N/A should be
used where the question is not applicable. The Company does not admit liability by the issue of this form.


INSURED                                            INTERMEDIARY                                          POLICY NO.

BUSINESS OR
                                                                           TELEPHONE NO. (DAY)
OCCUPATION

                                                                           E-MAIL ADDRESS


ADDRESS                                                                    INSURED’S VAT REG. NO.




VEHICLE

                                                                                                       REGISTRATION
MAKE                                   MODEL                               YEAR
                                                                                                         NUMBER

                                                                                             DATE OF
                                                   CURRENT                                  PURCHASE
GROSS VEHICLE MASS
                                                   VALUE                                     & PRICE
                                                                                               PAID

                                  CHASSIS OR                                                           KILOMETRES
COLOUR
                                    VIN NO.                                                            COMPLETED

                        FINANCE                                            TYPE OF                               AMOUNT
FINANCING DETAILS:
                        COMPANY                                           AGREEMENT                              OWING

IN WHOSE NAME IS THE VEHICLE REGISTERED? (PLEASE
ATTACH COPY OF REGISTRATION CERTIFICATES)

DAMAGE

DAMAGE TO OWN VEHICLE

ESTIMATE FOR REPAIR OR ATTACH QUOTATION

REPAIRER’S NAME, ADDRESS & TELEPHONE NUMBER,
E-MAIL & FAX NUMBER


WHERE CAN YOUR DAMAGED VEHICLE BE
INSPECTED?




                                                              Directors
                                                                                                                          1
                                                                      LOGO
                                                                  Registration No.
                                                              Postal & Physical Address
                                                                   Contact Details




DRIVER

FULL NAME

DATE OF BIRTH                                           TELEPHONE NUMBER.         (           )

ADDRESS
DRIVING                                                 DATE FIRST
                                NUMBER                                                PLACE       CODE:               FULL
LICENCE                                                 OBTAINED
(PLEASE
                                                                                                                      LEARNER
SUPPLY A COPY)

                                                                                                     WAS HE/SHE              YES
STATE FULLY THE PURPOSE FOR WHICH
                                                                                                  DRIVING WITH YOUR
THE VEHICLE WAS BEING USED
                                                                                                     PERMISSION?             NO
WHAT WAS YOUR
DESTINATION?
HAS HE/SHE ANY MOTOR INSURANCE ON HIS/HER                  YES
VEHICLE? IF YES, GIVE POLICY NO. AND NAME OF
COMPANY                                                     NO

DETAILS OF       ANY   CONVICTION      FOR   MOTORING
OFFENCES

                                 YES
IF YES, HAS LICENCE EVER
                                                  HAS HE/SHE ANY PHYSICAL DEFECTS?
BEEN ENDORSED?
                                  NO

IF YES,     PLEASE     SUPPLY
DETAILS




                                                                      Directors
                                                                                                                                   2
DETAILS OF PREVIOUS ACCIDENTS




OTHER PARTIES INVOLVED IN THIS ACCIDENT

                                           NAME                     ADDRESS                 INJURY




   PASSENGERS IN
  INSURED VEHICLE




                                                                                                             YES
 FOR WHAT PURPOSE WERE
                                                                                   ARE THEY EMPLOYEES?
      THEY CARRIED?
                                                                                                             NO


OTHER VEHICLES INVOLVED

 REGISTRATION NO.           MAKE / MODEL          COLOUR   NAME & ADDRESS OF OWNER AND DRIVER        DETAILS OF DAMAGE




                                                                                                                         3
DAMAGE TO PROPERTY OTHER THAN VEHICLES


            NAME AND ADDRESS OF OWNER                                           DETAILS OF DAMAGE




PERSONAL INJURIES (OTHER THAN IN THE INSURED VEHICLE) FOR INFORMATION PURPOSES ONLY

                                   RELATIONSHIP TO ACCIDENT                                            NAME OF HOSPITAL –
       NAME OF INJURED                                                    DETAILS OF INJURIES
                                          e.g. DRIVER                                                    IF APPLICABLE




WITNESSES


                     NAME                                                             PHONE NUMBER
WITNESS 1
                     ADDRESS                                                          E-MAIL ADDRESS

                     NAME                                                             PHONE NUMBER
WITNESS 2
                     ADDRESS                                                          E-MAIL ADDRESS




                                                                                                                            4
DECLARATION
ACCIDENT DETAILS


I/We hereby solemnly declare the foregoing particulars to be true in every respect
                                               AM
DATE                                                   TIME                              PLACE
                                                                        PM

SPEED BEFORE ACCIDENT                         kph
SIGNATURE of DRIVER __________________________________________________ DATE _____________________________
WEATHER CONDITIONS                                                                 VISIBILITY

                                                                               YES                                                     YES
   ROAD                              WIDTH OF                     VEHICLE
                                                                                                   STREET LIGHTING?
 SURFACE                               ROAD                     LIGHTS ON?
SIGNATURE of INSURED __________________________________________________ DATE _____________________________
                                                                                NO                                                      NO

                                         YES
WAS ANY WARNING GIVEN BY YOU                            (If YES, give specifics)
    It is important INDICATOR?
NB: e.g. HOOTING, that you notify the insurer immediately you become aware of any impending prosecution, inquest or claim
                                         NO

                            NAME OF POLICE OR TRAFFIC OFFICER                         POLICE STATION                        REFERENCE NUMBER
POLICY DETAILS


                              YES
WAS DRIVER TESTED FOR
                                                  RESULT OF TEST
 ALCOHOL OR DRUGS?
                              NO




PLEASE PROVIDE A BRIEF
  DESCRIPTION OF THE
      ACCIDENT




  SKETCH OF ACCIDENT

PLEASE SHOW CLEARLY
THE POINT OF IMPACT
AND     INDICATE     THE
DIRECTION OF TRAVEL BY
ARROWS. GIVE DETAILS
OF ANY ROAD SAFETY
SIGNS     OR   WARNING
SIGNS IN THE VICINITY OF
THE SCENE.




                                                                                                                                               5
DECLARATION



I/We hereby solemnly declare the foregoing particulars to be true in every respect


SIGNATURE of DRIVER __________________________________________________ DATE _____________________________




SIGNATURE of INSURED __________________________________________________ DATE _____________________________



NB: It is important that you notify the insurer immediately you become aware of any impending prosecution, inquest or claim




CLAIMS DEPARTMENT




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