Accident Claim Form
This form needs to be completed if you have been in an accident or want to submit a claim as a Claims Consultant.
Who is completing this form
Name and Surname of Claims Consultant (if applicable)
Your answer
Has the claim been registered at the RAF
If yes, please supply RAF claim number and date submitted
Your answer
Has attorneys been appointed to work on the claim before
If yes, submit name and contact details of attorney
Your answer
Name and Surname of Claimant
Your answer
Residential Address of Claimant
Your answer
Mobile Number of Claimant
Your answer
E-mail address of Claimant
Your answer
Identification number of claimant
Please send a copy of the claimant's Identification Document to info@libra-assessors.co.za .
Your answer
Date of accident
MM
/
DD
/
YYYY
Time of accident
Time
:
Address where accident took place
Your answer
Name of SAPS station from where police officials attended to the accident scene
Your answer
Accident Report or case number
Your answer
Name of hospital where the claimant was admitted
Your answer
Hospital file number
Your answer
Short description of injuries sustained
Your answer
Short description of how the accident happened
Your answer
Any other information which can help our assessors with the investigation
Your answer
Submit
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