Holburn Holdings (Pty) Limited Insurance Brokers VAT No

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1 Holburn Holdings (Pty) Limited Insurance Brokers VAT No Block C, Abrey Eco Park, 5 Abrey Road, Kloof, 3610 FSP Licence No P.O. Box 198, Gillitts, Fax: or Fax to SECTION A INSURED MOTOR ACCIDENT CLAIM FORM Insurer: Name: Occupation: Policy Number: Address: VEHICLE Make: Model: Odometer Reading: Value: Purchase Price: If vehicle is subject to a Hire Purchase, Credit or Leasing Agreement, state the name of the Finance Company Tare: Gross Vehicle Mass: Registration No: Date of Purchase: DAMAGE Damage to own vehicle: Where can your damaged vehicle be inspected? Is the vehicle safe to drive? Yes No DRIVER Full Name: Address: Occupation: Drivers Licence No Telephone: Drivers Licence Holburn Holdings (Pty) Limited Insurance Brokers Reg. No / / 07 Director: R.A. Burns (BA, LLB, AIISA) * British

2 DRIVER Drivers Licence Code: Drivers Licence Learners of Full: Was the vehicle being used with your permission? Was the driver in your employ? Has the driver any motor insurance? If YES, please state policy number: Details of convictions for motoring offences: Has the license been endorsed? Does the driver have any physical defects? Details of previous accidents: Advance Driving Course? If YES please attach certificate: Drivers Licence Place: Vehicle Use: If YES, please state the insurer: PASSENGERS (Insured Vehicle) Name and Surname Tel Address Injury For what reason were they transported? Are they employed? OTHER PARTY DETAILS (Please also complete Section B) Damage to other vehicle Name of owner and driver: Address of owner and driver: Registration no: Make/Model: Telephone: Damage to other vehicle Name of owner and driver: Address of owner and driver: Registration no: Make/Model: Telephone: Motor Accident Claim Form 2 of 5

3 Damage to property other than vehicles Name of owner: Address of owner: Tel. Personal Injuries (other than in insured vehicles) Personal Injuries (other than in insured vehicles) WITNESS Motor Accident Claim Form 3 of 5

4 ACCIDENT DETAILS Province: Suburb: Speed before accident: Speed on impact: Intersection: Weather conditions: Visibility: Road Surface: Width of road: Which vehicle lights were on? Street lighting: Was any warning, e.g. hooting, indication etc. given by you? Police Case No: Police Station: Was the driver tested for alcohol or drugs? If YES Result of test: Description of accident: (include closest intersections) Indicate on the graphic the area of damage sustained in the accident by clicking or selecting the relevant box and mark it with an X X RIGHT FRONT BACK LEFT BANK DETAILS Bank: Bank code: Account holder: Account no: Motor Accident Claim Form 4 of 5

5 DECLARATION We hereby declare the foregoing particulars to be true in every respect. Signature of Driver Signature of Insured Capacity: NB: It is important that you notify insurers immediately you become aware of any impending prosecutions, inquest or demand. SECTION B AUTHORISATION TO OBTAIN SAPS / COLLISION REPORT I, I.D. Number: hereby authorise Holburn Holdings (Pty) Ltd, in conjunction with who act as their Tracing Agents to obtain the SAPS / Collision Report on my behalf. Please contact Holburn Holdings (Pty) Ltd if you have any queries in this regard. (for office use only) Signature Motor Accident Claim Form 5 of 5

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