Declaration

I/We warrant the truth of the answers to the questions below and I/we declare that no information has been withheld and that the amount claimed represents my/our loss arising from the stated occurrence. By submitting this claim I declare herewith that I am the Insured in terms of this policy.

[* Indicates required fields]

Policy number:*
Surname or Company Name:
Initials:
Insured's ID Number:
Insured's e-mail address:
Phone number - Home:
Phone number - Work:
Cellphone number:
Date of the accident:
Time of the accident:
At what address did the accident occur?
Address line 1:
Address line 2:
Address line 3:
City:
Police/Traffic Department where the accident was reported:
Date reported and to whom (name):
Police/Traffic Department reference number:
Short Description of the accident:
For what purpose was the vehicle being used?
Details of the driver of the insured vehicle:

Surname:
Initials:
Title:
Relationship with insured (eg. self, child, friend, employee):
ID Number:
Driver's licence code:
Date issued:
Driving on Learner's Licence?


Had the driver consumed alcohol prior to driving?


Was a blood sample taken after the accident?


If a blood sample was taken what was the result?
Make of the vehicle:
Year of Manufacture:
Registration of the vehicle:
Is the vehicle insured under any other policy?


Name and address of the registered owner:

Surname:
Initials:
Address line 1:
Address line 2:
Address line 3:
City:
Province:
Postal code:
Estimated cost of repairs:
Do you have a quote for the repairs to the vehicle?


If yes, by whom?
Phone number:
Address where the vehicle may be seen:Address line 1
Address line 2:
Address line 3:
City:
Were there any other parties involved?


Third party details (Damages to other people's property)


Surname:
Initials:
Phone number - Home:
Phone number - Work:
Address of third party:Address line 1
Cellphone number:
Address line 2:
Address line 3:
City:
Have any passengers in your vehicle sustained injuries?


Make of other vehicle:
Registration number of other vehicle:
Eye witness?


Surname:
Initials:
Phone number - Home:
Cellphone number:
Phone number - Work:
I certify that the above information is correct.

I certify that I agree to the Declaration.*


Copyright © 2012 • Snyman Van der Vyver | All rights reserved