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

Policy Number
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SECTION 1: INSURED

Name & Surname:
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ID Number
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Email Address
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Occupation
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Address
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Cell Number
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Work Number
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Home Number
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SECTION 2: VEHICLE

Registration
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Field is required!
Year
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Make
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Model
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Section 3: DAMAGE

Repairer Name
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Repairer Telephone:
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Repairer Address
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Field is required!
Damage to own vehicle
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Current location of vehicle
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Field is required!

Is your vehicle under warranty

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Field is required!
Full description of broken or lost glass
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Field is required!

Is your vehicle under a motor plan?

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Field is required!
Windscreen clear, tinted, shatterproof or armour plate
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Field is required!

Section 4: DRIVER

Driver Name and Surname
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Driver ID Number
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Driver Email address
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Driver Occupation
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Field is required!
Driver Address
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Driver Cell Number
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Driver Work Number
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Driver Home Number
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Was he/she driving with permission?

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Field is required!

Has license ever been endorsed?

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Has he/she any physical defects?

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Field is required!
Purpose for which vehicle was being used
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Drivers license first issue date
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License Code
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Details of any convictions for motoring offences
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Details of previous accidents:
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Section 5: Passengers (insured vehicle)

Passenger 1 Name & Surname
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Passenger Address
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Field is required!
  • - Injury -
  • Yes
  • No
- Injury -
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Field is required!
Passenger 2 Name & Surname
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Field is required!
Passenger Address
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Field is required!
  • - Injury -
  • Yes
  • No
- Injury -
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Field is required!
Passenger 3 Name & Surname
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Field is required!
Passenger Address
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Field is required!
  • - Injury -
  • Yes
  • No
- Injury -
Field is required!
Field is required!

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 Name and Surname (Owner and/or Driver)
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Field is required!
Third Party ID Number
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Field is required!
Third Party Occupation
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Field is required!
Third Party Address
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Field is required!
Third Party Cell Number:
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Field is required!
Third Party Work Number
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Field is required!
Third Party Home Number
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Field is required!
Third Party Vehicle Registration
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Field is required!
Third Party Details of Damage
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Third Party Passenger
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Field is required!
Third Party Vehicle Make
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Third Party Insurance Detail
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Field is required!
Third Party Passenger Address:
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Field is required!
  • Third Party Passenger Injury:
  • Yes
  • No
Third Party Passenger Injury:
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Field is required!
Details of Injury
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Section 7: Accident

Select a date
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Select a time
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Place
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Police Station
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Reference Number
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Police Officer
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Speed traveling

Before Accident (km/h):
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At Impact
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Was the drive tested for alcohol or drugs?

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Weather conditions
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Visibility
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Road surface

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Description of accident
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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.

Witness Name and Surname
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Witness Address
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Witness Contact Number
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Capacity
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Date
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Date
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