Insurance Claim Form
ProVérte Risk Management (Pty) Ltd
Select your Advisor
Use the dropdown below to select your advisor
*
Your Advisor:
Cornel Bester
Déhan Marais
Francois Horn
Handró Griessel
Le Roux Ferreira
Raymond Meldau
Ruan Barnard
Willie Griessel
Select their assistant
*
Select Assistant
Celia de Wet
Terry-Lee Weyers
Select their assistant
*
Select Assistant
Leanda Le Roux
Suné Nel
Select their assistant
*
Select Assistant
Anke Von Molendorff
Claudi du Toit
Lizelle Brink
Select their assistant
*
Select Assistant
Lindy Lubbe
Sonja Swart
Select their assistant
*
Select Assistant
Colin Conradie
Ilze Gerber
Susan Maritz
Select their assistant
*
Select Assistant
Anèl Nel
Lucheal Milton
Select their assistant
*
Select Assistant
Abigail Matthee
Nodene Dippenaar
Select their assistant
*
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.
Format: (+27) 00 000 0000.
Policy Number
Enter 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)
Back
Next
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
*
Back
Next
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
Back
Next
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.
Format: (+27) 00 000 0000.
Email Address of third party
example@example.com
Back
Next
Attachments
Alarm Activation Report
Browse Files
Drag and drop files here
Choose a file
Cancel
of
List of Damaged or Stolen Items
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Damage report
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Quotations (To repair if repairable or for replacement if unrepairable).
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Police Report
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Photographs
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Any documentation relating to this claim
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
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
Back
Next
Vehicle details
Vehicle Make
*
Vehicle Model
*
Vehicle Year
Registration Number
*
VIN Number
Engine Nr
Back
Next
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
Back
Next
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
Back
Next
Witnesses
Please add witness details if applicable
Name & Surname
First Name
Last Name
Contact Number
Please enter a valid phone number.
Format: (+27) 00 000-0000.
Back
Next
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.
Format: (+27) 00 000-0000.
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
Back
Next
Attachments
Damage Report
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Quotations (To repair if repairable or for replacement if unrepairable).
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Invoice
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Photos
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Police Report
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Third party documentation
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Clear copy or photo of the driver’s license of the person driving the vehicle at the time of the incident.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
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: