Motor Accident Claim Form

Motor Accident Claim Form
by Charl du Plessis

Kindly note the following

  1. The purpose of this form is to register a valid motor accident claim with the insurance company.
  2. Please ensure that the authorised signature of the policy holder/representative appears on this form– it is illegal for any other personto sign this form.
  3. For JVC INSURANCE BROKERS to process this request quickly and correctly, please ensure that this form is completed in full.
  4. Please complete the form in black ink OR electronically and print clearly
  5. Where you need to make a choice between different options, please mark your selection with an X.
  6. This form is only valid for three months from the date signed.
  7. It is the responsibility of the insured to ensure that a claim is reported timeously. JVC INSURANCE BROKERS will not backdate any changes.
  8. If the spaces provided are not adequate, please attach a list with all relevant details.9.Please email the completed form to the claim’s handler appointed on your claim or to your broker.

Policy Holder

Vehicle Information

Driver Details

Accident Details

Third Party Details

Police Details

Repairer Details

Confirmation