MOTOR ACCIDENT CLAIM FORM
   
INSURER  
Name:    
:Policy No:    
Claim No:    
   
INSURED

 
Name:    
Address:    
Cell: Telephone No:
Fax No: Email Address:
Id No: Vat No:
   
VEHICLE
If vehicle is subject to hire purchase, credit or leasing agreement, state name, address and account number of finance company
Make:
 Tare:
Gross vehicle. Mass: Registration:
Km completed: Value:
Model & year: Purchase:
In whose name
is the vehicle
registered?
   
LOSS/DAMAGE PLACE
Damage to own
vehicle:

Estimate for
repairs or attach
quotation
Repairer’s name,
address and
telephone number
Where can your
damaged vehicle
be inspected?
   
DRIVER
Full Name:
Residential address:
Occupation:
Date of birth:
ID No:
Driving license:
State fully the
purpose for which
vehicle was being
used
Was he/she
driving with your
permission?		 Yes No
Was he/she in
your employ?		 Yes No
Has he/she any
motor insurance
on own car? If yes,
state policy no.
And company:
Details of any
convictions for
motoring offences:
Has license ever
been endorsed?		 Yes No
Has he/she any
physical defects?		 Yes No
Details of previous
accidents:
   
PASSENGERS
Passengers in insured vehicle
Name Residential Address Injury
 
   
For what purposes
were they carried?
Are they
employees?		 Yes No
   
OTHER PARTY
Personal injuries (other than in insured Vehicles)
Name of Injured Passenge / Driver Details of injuries Name of hospital, if
applicable
Yes No
 
This accident must be reported to the multilateral motor vehicle fund using the special accident report form (mmf3) within 14 days if there is any likelihood of injuries, otherwise the fund may be able to recover from you. The fund’s address is PO Box 2743, pretoria 0001
 
Other Vehicles
Registration No. Make Name & address of owner and driver Details of damage
Property other than vehicles
Name of Owner Address of Owner Details of Damage
 
WITNESS
Name of Owner Address of Owner Details of Damage
ACCIDENT
Date:
Time:
Place:
Speed before accident kph
Monment of impact: kph
Weather condition:
Visibility:
Road Surface:
Widh of road:
Which vehicle lights were on?
Street lighting: Yes No
Was any warning given by you e.g. Hooting,
indicators, etc?		 Yes No
Name of police officer who recorded details of accident.
Police station & reference no.
Was the driver
tested for alcohol
or drugs?		 Yes No
Description of
Accident
Click here to draw a sketch of accident, alternatively fax a sketch to
031 242 6850
   
DECLARATION
We hereby declare the foregoing particulars to be true in every respect:
   
Signature: