MOTOR ACCIDENT FORM
PLEASE NOTE THAT ALL CLAIMS MUST BE SUBMITTED WITHIN 30 DAYS OF THE DATE OF EVENT.
Claim Information:
Rows
Information
Policy Holder:
Policy Number:
Date of event:
Time of event:
Details of own vehicle involved at time of accident:
Rows
Information
Year , make and model
Registration number:
Damages to your vehicle?
Is the vehicle under warranty
Is the vehicle financed
Address of event:
Police case number:
Police Station reported:
Date reported:
Driver of vehicle (attach copy of ID)
Licence First date of issue(attach copy of ID)
Code: (B, EB, EC, C1)
Is vehicle drivable:
Address where vehicle is located:
Repair & towing Information:
Rows
Information
Prefered Panel beater
In which area must a panel beater be appointed.
If your vehicle has been towed
Name of towing company
Address ot towing company
Contact details of towing company
Third party details , if applicable:
Rows
Information
Make, model and reg no of third-party vehicle
Name and Surname:
Identity Number:
Address
Insurance Details of third party
Email address of third party
Contact number:
DESCRIPTION OF HOW ACCIDENT OCCURRED
Please provide full details
Upload Vehicle Damage Photos:
SKETCH OF ACCIDENT
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