accident report form (sections 22(1)(a) of act no. 56 of 1996
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- Shana York
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1 1) When any person has been injured or killed as a result of the driving of a motor vehicle, the owner and / or the driver of that motor vehicle must report that accident to the Fund on this form within 14 days, failing which the compensation paid to the third party may be recovered from that owner or driver. 2) Should the space provided in this form be insufficient to answer any question you are welcome to attach a further page(es) to this form in which such further information can be provided to the RAF. 3) Should you require any assistance with the completion of this form please feel free to contact the RAF on ShareCall number Postage will be paid by the addressee No postage necessary if posted in the Republic of South Africa CHIEF EXECUTIVE OFFICER P O Box 2743 PRETORIA particulars of the driver of the vehicle: ID number/passport number Citizenship Telephone Drivers license number Facsimile Date issued Endorsements, if any Physical / mental defects, if any State whether you are also the owner of the vehicle page 1
2 2 particulars of the owner of the vehicle - complete where the driver was not the owner: s ID number/passport number Citizenship 3 particulars of the motor vehicle: Make Body (i.e. sedan, truck, bus, etc.) Model Colour Year 4 particulars of other motor vehicles involved in the accident: Vehicle 1 Vehicle 2 and surname of driver and surname of driver / / and surname of owner and surname of owner page 2
3 4 particulars of other motor vehicles involved in the accident: Vehicle 3 Vehicle 4 and surname of driver and surname of driver / / and surname of owner and surname of owner 5 particulars of the accident: What was the date of the accident? At which police station was the accident reported? What was the time of the accident? What is the police reference number? Where did the accident take place? 6 particulars of witness(es) to the accident: Witness 1 page 3
4 6 particulars of witness(es) to the accident: Witness 2 6 particulars of witness(es) to the accident: Witness 3 page 4
5 10 7 particulars medical treatment of person(s) in medical injured/deceased: facility/hospital Person 1 State whether the injured / deceased was a driver, passenger, cyclist or pedestrian. 7 particulars of person(s) injured/deceased: Person 2 State whether the injured / deceased was a driver, passenger, cyclist or pedestrian conditions medical treatment the time in of medical the accident: facility/hospital Time of day (i.e. dawn, day, dusk, night) Street lights - on or off Weather conditions (i.e. sunny, misty, cloudy, raining, etc) Own vehicle s lights - off, dim, bright Visibility (i.e. good, reasonable, bad, etc.) Other vehicle s lights - off, dim, bright Road surface (i.e. gravel, sand, tar, etc.) Speed of own vehicle at time of accident page 5
6 9 sketch plan of the scene of the accident: N W E S 10 detailed description of the accident: page 6
7 11 declaration: I / we hereby declare that to the best of my / our knowledge and belief the information set out in this form is true and correct in every respect. Signature of driver Signature of owner Signed at Date YYYY/MM/DD page 7
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