Details of Helivac RAC Claim A. Claimant details 1. Title: 2. Surname: 3. Name: 4. Date of birth: 5. ID number / Passport number: Note: A certified legible copy of your identity document must be attached to this claim form 6. HELIVAC Membership number: 7. Residential address: 8. Postal address: 9. Home telephone number: 10. Work telephone number: 11. Cellular number: 12. Email: 13. If our claim is successful the RAF will pay you directly. Please provide bank account details for payment of compensation due to you. 13.1. Bank (Name) Account number: 13.2. Branch number: 13.3. Name of account holder:
Kindly attach one of the following documents to the claim form to enable the RAF to verify the banking details: a cancelled cheque or a certified legible copy/original statement of account which clearly indicates the account holder s name, account and branch number, or an original letter from the bank (on an official letterhead) which confirms the account holder s name, account and branch number. E B. Details of Accident 1. Date of accident: 2. Time of accident: 3. Place of accident (street number and name, suburb, town, province): 4. Immediately after or during the accident did you call the HELIVAC Medical Call Centre? If not specify the reason why. 5. Please confirm which of the following you were at the time of the accident: Driver Passenger Motorcyclist Motorcycle passenger Cyclist Pedestrian
6. In an affidavit, to be attached to this claim form, please describe how the accident occurred. 7. SAPS Accident report number: 8. Address of SAPS station where the accident was reported: 9. If you were a passenger and injured, what is the registration number of the vehicle in which you were a passenger: 10. If you were a cyclist or a pedestrian, what is the registration number(s) of the other vehicle(s) involved in the accident? 11. What is the driver s name and surname? If you answered 9 or 10. 12. Driver s physical address? If you answered 9 or 10. 13. Driver s contact number: 14. If you were the driver, what is the registration number of the motor vehicle / motorcycle driven by you (or the injured/ deceased)? 15. If you (or the injured / deceased) are not the OWNER of the motor vehicle / motorcycle kindly furnish the following information in respect of the owner - 15.1. Name and surname: 15.2. Telephone number: 15.3. Cell number: 15.4. Physical address:
16. Please provide details of any other vehicles involved in this accident. (Pedestrians and cyclists, must also answer this question by providing details of the vehicles involved.) 16.1. Registration number: 16.2. Driver s contact number: 17. Was this a hit-and-run accident? Yes / No 18. If someone is deceased 18.1. Name of deceased: 18.2. Surname: 18.3. Date of deceased: 18.4. What is your relationship to the deceased? 18.5. ID number of deceased: 18.6. Date of birth: 18.7. Kindly attach a copy of the death certificate, inquest report or charge sheet. 19. If in a motor vehicle, kindly indicate whether you (or the injured) were wearing a seatbelt at the time of the accident? Yes / No or If on a motorbike or cycling, kindly indicate whether you (or the injured) were wearing a helmet at the time of the accident? Yes / No
C. Claim 1. To assist the HELIVAC RAC with the processing of the claim, for past and / or future loss of income, please indicate the documents you can provide to confirm the members / deceased s earnings: Pay-slips Most recent tax return Printout of payments from employer Bank Statements Other Please specify: Printout of payments from employer Kindly attach copies of the documents identified by you to this claim form. 2. Tax reference Number 3. If the injured / deceased was self-employed please complete the following details 3.1. Business name: 3.2. Nature of business: 3.3. Business address: 3.4. Identify the applicable legal entity in respect of the injured / deceased business- Sole trader Partnership Trust Other Please specify: 4. If applicable, kindly furnish the Company / Close Corporation / Trust registration number of the business: 5. Has the injured / deceased / business lodged tax returns during last 3 financial years: Yes / No 5.1. If you answered YES, please attach copies of those tax returns to this claim form
5.2. If you answered NO, please attach income and expenditure statements / bank statements for the business, for the past 3 years or for such shorter period that the injured / deceased has been in business. D. Dependents Please furnish the requested details of all the persons who, at the time of death, were dependent on the deceased for support Dependent 1 Name: Date of birth: ID number: Relationship: Reason for dependence: Dependent 2 Name: Date of birth: ID number: Relationship: Reason for dependence: Dependent 3 Name: Date of birth: ID number: Relationship: Reason for dependence:
Dependent 4 Name: Date of birth: ID number: Relationship: Reason for dependence: Dependent 5 Name: Date of birth: ID number: Relationship: Reason for dependence: Note: As proof of the relationship between the deceased and the particular dependent please attach certified copies of the relevant documentation, i.e. marriage certificate unabridged birth certificate, adoption court order, etc. (Should this claim form not provide enough space to list all the dependents kindly list the remaining dependents on a separate page to be attached to this claim form) E. Consent 1. The Consent granted to HELIVAC RAC in this paragraph authorizes the HELIVAC RAC to obtain copies of any records and to access any information which relates to this claim for compensation and to contact any person or entity for purposes of obtaining or verifying such information and /or documentation. 2. I, (name and surname of claimant), declare that, to the best of my knowledge, the information provided in this Third Party Claim Form is true and correct in every respect; and 3. I confirm that I am claiming compensation:
in my personal capacity as a result of injuries I sustained in the accident; alternatively in my personal and / or representative capacity as (state capacity) on behalf of (name and surname of injured) who sustained injuries in the accident; alternatively in my personal and / or representative capacity as (state capacity) of (name of the deceased) who died as a result of the injuries sustained in the accident. (Indicate, and if applicable complete, the applicable statement above) 4. I hereby consent to the release, (to HELIVAC RAC), of copies of all documentation and /or information, including, but not limited to, documentation and /or information of a medical or financial nature, in the possession of any person or entity, which documentation or information, in any way, relates to this claim for compensation arising from the motor vehicle accident detailed in the claim form 5. I further consent to, and authorize, HELIVAC RAC to contact any person or entity for purposes of obtaining or verifying such information and /or documentation. Signature of the Claimant Signature of the Witness
Documents to be Attached Certified copy of ID must be attached to this claim form (refer to clause A) Verify bank details: Cancelled cheque. Certified legible copy/original statement of account which clearly indicates the account holders name, account, branch number. Original letter from the bank (official letterhead) which confirms the account holders name, account and branch code. Affidavit describing how the accident occurred (refer to clause B) If Someone is deceased- Copy of death certificate, inquest report or charge sheet Proof of income If Yes (Lodged tax returns) - attach copies of tax returns (refer to clause C) If No- Income and expenditure statements for business for the past 3 years or for such shorter period that the injured, deceased has been in business. (refer to clause C)