011 879 7200 / 7250

St Andrews Office Park

39 Wordsworth Avenue, St Andrews.

Stay informed! Visit the SA Department of Health’s website for COVID-19 updates: sacoronavirus.co.za

011 879 7200 / 7250

St Andrews Office Park

39 Wordsworth Avenue, St Andrews.

Motor Accident Claims Form

SECTION 1: INSURED

SECTION 2: VEHICLE

Section 3: DAMAGE

Is your vehicle under warranty

Is your vehicle under a motor plan?

Section 4: DRIVER

Was he/she driving with permission?

Has license ever been endorsed?

Has he/she any physical defects?

Section 5: Passengers (insured vehicle)

  • - Injury -
  • Yes
  • No
  • - Injury -
  • Yes
  • No
  • - Injury -
  • Yes
  • No

Section 6: Third Party (damage to other vehicles/ property)

NB: Please notify the Insurers immediately if you become aware of any impending prosecution, inquest or demand!

  • Third Party Passenger Injury:
  • Yes
  • No

Section 7: Accident

Speed traveling

Was the drive tested for alcohol or drugs?

Road surface

I / we declare that to the best of my/our knowledge the above information is true in every aspect.


NB I acknowledge that should I elect to use a non-manufacturer approved repairer I release Pogo Group from any liability which could arise as a result of any defective workmanship. I acknowledge further that I may lose my manufacturer’s warranty and or maintenance plan that may exist on my vehicle.

Driver Signature
Insured Signature
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