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CLAIM DETAILS

In order for us to start processing the claim, we need certain details to enable us to complete the prescribed forms. If you are acting as a representative of the person who was injured (eg. your minor child), please put your details in item 2. The rest of the form relates to the injured person.

If you want to know whether you have a claim before spending any more time on this, please phone us on 032-9463646 and we will gladly give you an indication.

  1. Full names of injured person 
  2. Full names of representative, if applicable and relationship to injured person  and phone
  3. Residential address:   
  4. Citizenship:       If "Other" please state:
  5.   ID or passport number:   
  6. Marital Status        If married   
  7. Phone numbers including code:    Work        Home:   
  8. Employment status   If employed, what occupation   
  9. The injured person was  when the accident happened. If  the driver or a passenger, what was the registration of the vehicle in which you were traveling
  10. What is the registration of the vehicle that caused the accident   
  11. What is the name and address of the driver of that vehicle (leave blank if you don't know):   
  12. Time of accident:   Hour Minutes     Day    Month     Year
  13. Where did the accident happen   
  14. Was it reported to the Police        If yes, please give name of the Station and their reference number   
  15. If you were treated by a doctor, please give his name phone and address
  16. If you have a usual doctor, please give his name phone number and address
  17. Were you working at the time of the accident     
  18. If yes, can you claim Workmen's Compensation?    Do you know how much
  19. E-Mail address 
  20. Please give a brief description of your injuries

 

21. Please give a brief description of how the accident happened