HOME
ABOUT US
PRODUCTS
PERFECT DELIVERY
Claims
NEWS
CONTACT US
MOTOR ACCIDENT CLAIM FORM
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 3
Policyholder Information / Polishouer-besonderhede
Kindly complete all relevant info below
Voltooi die onderstaande met die inligting soos versoek.
Initials and Surname / Voorletters en van
*
Policy Number / Polisnommer
*
ID Number / ID-nommer
*
Home Address / Huisadres
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Telephone Number / Telefoonnommer
*
Email Address / E-posadres
Email
Confirm Email
Next
Date and time of accident / Datum en tyd van ongeluk
*
Date
Time
Please use the above tool to pick the time and date of our accident
Place of accident / Plek van ongeluk
*
Vehicle / Voertuig
*
Please describe the type, make and model of the vehicle involved in the accident
Registration Number / Registrasienommer
*
VIN Number / VIN (nommer
*
Driver at the time of accident / Bestuurder ten tye van ongeluk
*
Registered owner / Geregistreerde eienaar
*
Description of accident / Beskrywing van ongeluk
*
Please provide photos if available / Verskaf asseblief foto’s indien beskikbaar
File Upload
Click or drag files to this area to upload.
You can upload up to 12 files.
Please use this function to upload your photos / Gebruik asb die funksie om U fotos op te laai.
SAPS Case No / SAPD-saaknommer
*
Next
Police Station / Polisiestasie
*
Name of third party / Naam van derdeparty
*
First
Last
ID Number / ID-nommer
*
Contact number / Telefoonnommer
*
Registration number / Registrasienommer
*
Is the property being claimed for insured anywhere else? / Is die eiendom waarvoor geëis word, elders verseker?
Yes / Ja
No / Nee
Not sure / Ek weet nie
I/We acknowledge that the sharing of claims information by insurers is essential to enable the insurance industry to underwrite policies and assess risks fairly and to reduce the incidence of fraudulent claims. In the public interest and with a view to limiting premiums, I/we waive any right to privacy for any insurance or claims information supplied by me/us or on my/our behalf in respect of any insurance application or claim made or lodged by me/us and I/we consent to such information being disclosed to any other insurance company or its agent. I/We also waive any rights to privacy and consent to the disclosure of any information relevant to any insurance claim concerning me/us or any insured person I/we represent. I/We further declare that all particulars are true in every respect and correct. I/we understand that if any claim submitted in terms of this policy shall be fraudulent in any respect or if any fraudulent means or devices are used by me/us or anyone acting on my/our behalf or with my/our knowledge or consent to obtain any benefit under this policy or if any event shall be occasioned through the wilful act or with my/our connivance, the benefit afforded under this policy in respect of such claim shall be forfeited.
Date / Datum
*
Submit
Menu
This website uses cookies to improve your experience. If you continue to use this site, you agree with it.
I AGREE