Telephone:
+27 87 135 8788
Email:
claims@rtusa.co.za
Website:
www.rtusa.co.za
Physical Address:
29 Bond Street, Ferndale, Randburg. 2194
FSP 39312
Underwritten by Renasa Isurance Company Limited
Motor Accident Claim Form : Insured
Company/Surname
Initials
Title
Mr
Mrs
Miss
Dr
Adv
Prof
Policy Number
ID/Passport Number or Co Registration Number
Email
Name
Occupation
Address
Day Telephone Number
Vehicle
Make
Registration
Model
Model Year
Kilometers Completed
State Name, and Account Number of Finance Company
Chassis/VIN No
In whose name is the vehicle registered?
Damage
Damage area to own vehicle
Indicate old damage on vehicle
Estimate for repairs or attach quotation
Where can your damaged vehicle be inspected?
Repairer’s name
Repairer's Address
Repairer's Telephone Number
Driver
Full Name
Residential Address
Occupation
ID/Passport Number
Drivers Licence Card Number
License Type
Date of issue
State fully the purpose for which the vehicle was being used
Was he/she driving with your permission?
Yes
No
Has he/she motor insurance on own car? If yes state Policy Number and Company
Yes
No
Has license ever been endorsed?
Yes
No
Has he/she any physical defect?
Yes
No
Details of previous accident
Passengers (Insured Vehicle)
How many passenger were in the vehicle?
0
1
2
3
4
1st Passenger Details
Name
Residential Address
Injury
2nd Passenger Details
Name
Residential Address
Injury
3rd Passenger Details
Name
Residential Address
Injury
4th Passenger Details
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
Relationship to accident e.g. [driver, passenger etc]
Details of injuries
Name of Hospital if applicable
Other Vehicles Involved
Registration
Make
Name of owner
Contact Number
ID/Passport Number
Details of damage
Old damage
Address of owner & driver
Colour of vehicle
Independent Witnesses
How many witnesses do you have?
1
2
3
1st Witness Details
Name
Address
Telephone Number
2nd Witness Details
Name
Address
Telephone Number
3th Witness Details
Name
Address
Telephone Number
Third Party Details
Is there a third party involved?
No
Yes
Third Party Name
Third Party Surname
Is Third Party insured?
No
Yes
Insurer Name
Policy Number
Accident Details
Place where the accident took place
Date of the accident
Time of the accident
Speed before accident (kp/h)
Moment of impact (kp/h)
Weather conditions
Visibility
Road surface
Width of road
Which vehicle lights were on?
Were Street lights on?
No
Yes
Name of Police/Traffic officer
Police station where accident was reported
Case Number
Date reported
Was driver tested for alcohol or drugs
No
Yes
Description of accident
Insurers share information with each other regarding domestic policies and claims with a view to prevent fraudulent claims and obtain material information regarding the assessment of risks proposed for insurance. Please refer to the Consent Clause on the policy schedule for more details in this regard.
Declaration
We hereby declare the aforegoing particulars to be true in every respect.
Signature of Driver
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Capacity
Date
Signature of Insured
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Capacity
Date
N.B. IT IS IMPORTANT THAT YOU NOTIFY THE INSURERS IMMEDIATELY YOU BECOME AWARE OF ANY IMPENDINGPROSECUTION, INQUEST OR DEMAND
SUBMIT