MOTOR ACCIDENT CLAIM FORM

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MOTOR ACCIDENT CLAIM FORM
MOTOR ACCIDENT CLAIM FORM
(Delete section not applicable)
INSURER
POLICY NO.
INSURED
VEHICLE
DAMAGE
Name and occupation
Identity Number
Address and day phone
number
Make
Tare
Gross vehicle mass
Kilometres completed
Registration number
Value
Model and year
Date of purchase and price
paid
If vehicle subject to Hire
Purchase, Credit or Leasing
Agreement, state name and
address of finance company
In whose name is vehicle
registered?
Damage to own vehicle
Estimate for repairs or attach
quotation
Repairer's name, address and
telephone number
Where can your damaged vehicle
be inspected?
Full Name
Address
Occupation
Identity Number
Driving Licence
DRIVER
Number
Date First
Issued
Place Issued
Code
Full/Learner
State full the purpose for which
the vehicle was being used
Was he/she driving with your
permission?
Was he/she in your employ?
Is he/she owner of another
vehicle? Is yes, give name of
Insurer and policy number
Details of any convictions for
motoring offences
Has licence ever been endorsed?
Has he/she any physical defects?
Details of previous accidents
PASSENGERS IN INSURED
VEHICLE
PASSENGER
S
((Insured vehicle)
For what purpose were they
carried?
Are they employees?
Name
Address
Injury
Make and registration
number
Name, address and telephone
number of owner and driver
Details of damage
OTHER VEHICLES
Name and address of Owner
OTHER
PARTY
Name of Injured
PERSONAL
INJURIES (IN
OTHER
VEHICLES)
WITNESSES
Details of damage
PROPERTY (NOT
VEHICLES)
Name, address and day
phone no.
Relationship to accident
e.g. Driver, Passenger
etc.
Details of
injuries
Name of
hospital (if
applicable)
1.
2.
Date, Time, Place
Speed
a)
Before accident
Weather
a)
conditions
b) Visibility
a) Road surface
a)
b) Width of road
a) Which vehicle
a)
lights were on?
b) Street lighting
Was any warning given by you, e.g. hooting, indicator
etc.?
Name of Traffic Officer who recorded
details of accident
Police Details
Was driver tested for
alcohol or drugs?
ACCIDENT
DESCRIPTION OF
ACCIDENT
After accident
b)
b)
b)
Police Station and Case number
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 vicinity of scene of accident
AUTHORITY
FOR PAYMENT
It is recommended that any amount payable to you direct be transmitted by Electronic Bank
Transfer for speedier settlement and security reasons. If you are agreeable to this, please provide
the following information:
ASSIGNMENT:
I/We acknowledge that the party hereby authorised to effect a credit against my/our account may
not cede or assign any of its rights to any third party without my/our prior written consent and
that I/We may not delegate any of my/our obligations in terms of this contract/authority to any
third party without prior written consent of the authorised party.
NAME OF BANK:
………………………………………………………………………………………….
BRANCH AND CODE NO. ………………………………………………………………………………….
ACCOUNT NO.
…………………………………………………………………………………………
NAME OF ACCOUNT HOLDER
…………………………………………………………………………….
SIGNATURE: …………………………………………………………………………………………………..
DECLARATION
We hereby declare the aforegoing particulars to be true in every respect.
Signature of driver…………………………….
Signature of insured:…………………………
Date:
………………………………………..
Date: ………………………………………….
N.B. IT IS IMPORTANT THAT YOU NOTIFY THE INSURERS IMMEDIATELY YOU
BECOME AWARE OF ANY IMPENDING PROSECUTION, INQUEST OR DEMAND.

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