Vehicle Accident Claim Form

General Claims Information

Vehicle Accident Claim Form

  • Policy number:

  • Surname or Company Name

  • Initials

  • Identity Number

  • Email Address

  • Phone number - Home

  • Phone number - Work

  • Cellphone number

  • Date of the accident

  • Time of the accident

  • At what address did the accident occur?

  • City

  • Police/Traffic Department where the accident was reported

  • Date reported and to whom (name)

  • Police/Traffic Department reference number

  • The Vehicle Make

  • Short Description of the accident *

  • For what purpose was the vehicle being used? *

  • The details of the driver of the vehicle

  • The driver of the vehicle at time of accident is the same person as the policy holder

  • Driver's Surname

  • Driver's Initials

  • Driver's Title *

  • Relationship with insured (eg. self, child, friend, employee)

  • Driver's ID Number

  • Driver's licence code

  • Date issued

  • Driving on Learner's Licence?

  • Had the driver consumed alcohol prior to driving?

  • Was a blood sample taken after the accident?

  • If a blood sample was taken what was the result?

  • Make of the vehicle

  • Year of Manufacture

  • Registration of the vehicle

  • Is the vehicle insured under any other policy?

  • Name and address of the registered owner

  • Surname

  • Initials

  • Address

  • City

  • Province

  • Postal code

  • Estimated cost of repairs

  • Do you have a quote for the repairs to the vehicle?

  • If yes, by whom?

  • Phone number

  • Address where the vehicle may be seen

  • City

  • Have any passengers in your vehicle sustained injuries?

  • Make of other vehicle

  • Registration number of other vehicle

  • Eye witness?

  • Eye witness Surname

  • Eye witness Initials

  • Eye witness Phone Number Home

  • Eye witness Phone Number Work

  • Eye witness Cellphone Number

  • Third Party involved in accident:

  • Name and Surname:

  • Identity number:

  • Vehicle registration number:

  • Type of vehicle:

  • Telephone / Cellphone number:

  • Other details:

  • Please draw a SKETCH of accident and mail to: info@svdv.co.za

  • *

  • Attachment Upload

  • Accepted file types: pdf, jpg, png.
  • Please complete Captcha Code

  • This field is for validation purposes and should be left unchanged.