Insurance Claim Form
ProVérte Risk Management (Pty) Ltd
Select your Advisor
Use the dropdown below to select your advisor
*
Your Advisor:
Cornel Bester
Francois Horn
Handró Griessel
Le Roux Ferreira
Raymond Meldau
Ruan Barnard
Willie Griessel
Déhan Marais
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*
Select Assistant
Celia de Wet
Terry-Lee Weyers
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*
Select Assistant
Leanda Le Roux
Suné Nel
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*
Select Assistant
Abigail Matthee
Anke Botes
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*
Select Assistant
Lindy Lubbe
Sonja Swart
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*
Select Assistant
Ilze Gerber
Cindy Swanepoel
Susan Maritz
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*
Select Assistant
Anèl Nel
Lucheal Milton
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*
Select Assistant
Nodene Dippenaar
Lizelle Brink
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*
Select Assistant
Naomi Willemse
Policyholder Information
Name and Surname of the insured
*
First Name
Surname
Email of the insured
*
example@example.com
Contact Number of the insured
*
Please enter a valid phone number.
Policy Number
What type of incident you want to submit the claim?
Select the type of incident you want to claim for:
*
Select Incident Type
Motor
Non-Motor
Non-Motor Options:
*
Select One
Geyser / Burst Pype
Property Loss or damage
Liability
Motor Options:
*
Select One
Windscreen / Motor Vehicle Glass
Vehicle Theft / Hijack
Accident / Collision
Liability (Third party claim only – no own damage)
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Event Information
Date of the incident
*
-
Day
-
Month
Year
Date
Time of the incident
*
Hour Minutes
AM
PM
AM/PM Option
Place / Address of incident
Street Name
*
Street Name
Street Number
Street Number
City
*
City
Postal Code
Postal Code
Province
*
Please Select
Western Cape
Northern Cape
Eastern Cape
KwaZulu-Natal
Free State
North West
Gauteng
Mpumalanga
Limpopo
Province
Description of incident
*
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Theft
Is this a theft or burglar claim?
*
Yes / No
Yes
No
Police Case Number:
Name of police station where the incident was reported.
Date the incident was reported on.
-
Day
-
Month
Year
Date
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Loss caused by other parties
Was the incident caused by other parties
*
Yes / No
Yes
No
Name and Surname of third party:
First Name
Last Name
Contact Number of third party
Please enter a valid phone number.
Email Address of third party
example@example.com
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Attachments
Alarm Activation Report
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of
List of Damaged or Stolen Items
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of
Damage report
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of
Quotations (To repair if repairable or for replacement if unrepairable).
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of
Police Report
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of
Photographs
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of
Any documentation relating to this claim
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of
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Event Information
Date of the incident
*
-
Day
-
Month
Year
Date
Time of the incident
*
Hour Minutes
AM
PM
AM/PM Option
Street Name
*
Street Name
Street Number
Street Number
City
*
City
Postal Code
Postal Code
Province
*
Please Select
Western Cape
Northern Cape
Eastern Cape
KwaZulu-Natal
Free State
North West
Gauteng
Mpumalanga
Limpopo
Province
Description of incident
*
Was the driver tested for alcohol or drug use
*
Yes / No
Yes
No
Is the vehicle drivable?
Yes / No
Yes
No
Was the vehicle recovered or not?
Yes / No
Recovered
Not Recovered
Name of the panel beater of your choice
Name of Glass Supplier of your choice
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Vehicle details
Vehicle Make
*
Vehicle Model
*
Vehicle Year
Registration Number
*
VIN Number
Engine Nr
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Police
Was the incident reported to the police?
*
Yes / No
Yes
No
Police Case Number
Name of Police Station where it was reported
Date on which the incident was reported
-
Day
-
Month
Year
Date
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Details of driver
Was the vehicle parked /stationary at the time of the accident or not?
*
Yes / No
Yes
No
Full Name of the driver
*
IDnr of the driver
*
Was the driver using the vehicle with the insured’s permission?
*
Yes / No
Yes
No
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Witnesses
Please add witness details if applicable
Name & Surname
First Name
Last Name
Contact Number
Please enter a valid phone number.
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Third party
Please add third party details if applicable
Third party Name & Surname
First Name
Last Name
Third party contact number
Please enter a valid phone number.
Third party email address
example@example.com
Are the third party insured
Yes / No / Unsure
Yes
No
Unsure
Third party vehicle make
Third party vehicle Model
Third party vehicle year
Third party registration Number
Third party VIN Number
Third party Engine Nr
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Attachments
Damage Report
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Drag and drop files here
Choose a file
Cancel
of
Quotations (To repair if repairable or for replacement if unrepairable).
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of
Invoice
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of
Photos
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of
Police Report
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of
Third party documentation
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of
Clear copy or photo of the driver’s license of the person driving the vehicle at the time of the incident.
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of
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Declaration
I/we declare that to the best of my/our knowledge the above statements are true. I acknowledge that the information set out above is provided freely so that the insurer may process my claim as per the policy wording. I understand that I may be liable for output VAT in terms of section 8(8) of the VAT Act 89 of 1991.
*
I accept the terms & conditions.
Capacity
*
For example "Policyholder"
Date of completing this claim
*
-
Day
-
Month
Year
Date
Signature
First Name
Last Name
Submit
Should be Empty: