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.

Personal Liability Claims Form

Policy Number
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SECTION 1: INSURED

Name and Surname:
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Address
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Email 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: INCIDENT

Select a date
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Place of incident
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SECTION 3: WITNESS

Name and Surname of witness
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Address
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Contact Number:
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SECTION 4: POLICE

Police Station
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Police reference number
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Date
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SECTION 5: TYPE OF LOSS/DAMAGE

Type of loss/damage
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SECTION 6: PERSONAL INJURIES (IF APPLICABLE)

Name of injured person
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Address
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Age
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Relationship with the injured
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Details of injury
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SECTION 7: CLAIM

Claim (if any claim has been or is being made against you, give details and attach any correspondence)
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Upload claim correspondence..
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SECTION 8: DESCRIPTION OF INCIDENT

Describe exactly how the incident occured
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SECTION 9: DECLARATION

I/ We hereby declare that to the best of my/our knowledge the above statements are true.

Capacity
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Date
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