“Partners in your Risk”
Please complete this form and return it back with the required documentation and information.
Please note that we will not be able to process your claim without the documents and information requested on this form.
A claim against M&F Risk Financing, the broker we represent and their insured can take up to 8 weeks to
finalise, and we need to inform you that the follow-up lies with you.
Please note that M&F Risk Financing is not party to the Knock-for-knock agreement as of 01.06.2013.
The documents must be forwarded to: Belinda Bardenhorst email@example.com
Claim number: ________________________ Client: ____________________________________
THIRD PARTY DETAILS:
Home tel.: ____________________________ Work tel.: _________________________________
Cell no.: ______________________________ E-mail: ____________________________________
Vehicle information for appointing an assessor:
Registration number of vehicle: ___________________________________________________
Make of your vehicle: ______________________________________________________________
The year model: __________________________________________________________________
Where is your vehicle currently: _____________________________________________________
Is your vehicle driveable [YES/NO] ___________________________________________________
Was your vehicle towed from the accident scene [YES/NO] _______________________________
If “YES” please advise us where your vehicle was towed to. E.g. Panel beater/ Towing Company or Residential
If towed to a Towing Company kindly provide us with a copy of the towing invoice.
Please note that if your vehicle is standing at a Towing Company/Panel Beater’s premises we will not be responsible for the storage, security and admin fees.
We do not pay car hire costs, unless the vehicle is used for business purposes to generate income and proof will be required.
Required Documentation from the Third Party is as follows:
If you do have an independent witness, not a passenger in your vehicle, please advise your witness to
complete the witness form below:
WITNESS STATEMENT FORM:
Full names: _______________________________________________________________________
Home Address: ____________________________________________________________________
Work Tel.: ________________________________ Cell no.: _________________________________
E-mail address: _____________________________________________________________________
When, where and how did the accident happen:
Date of accident: ________________________________ Time: _____________________________
Weather conditions: ______________________________ Visibility: _________________________
Vehicles involved: __________________________________________________________________
Where were you at the time of the accident: _____________________________________________
Please give us the detailed description of how the accident happened:
Please draw a sketch showing the accident and indicate where you were at the time of the accident:
SIGNITURE: _________________________________ Date: ________________________________________