MJD Risk Insurance Brokers

Short Term Insurance and Risk Management Consultants

“Partners in your Risk”

Direct TP claims procedure

Table of Contents

Direct TP claims procedure #

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 belinda@stratsys.co.za

CLIENT DETAILS:

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

place ___________________________________________________________________________

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:

Vehicle:

  • Vehicle Registration Certificate (NOT the Vehicle License Certificate); please note the reason why we require a copy of your vehicle registration is to prove ownership in the event that you are claiming for damages on a vehicle.
  • Copy of ID of the registered owner;
  • SAP number or police report
  • Copy of the driver’s license [the person driving at the time of the collision]
  • Sketch and description of how the accident happened (to be done by the driver at the time of the accident);
  • If you do not have insurance please provide a letter (known as a no claim letter) from you insurer confirming that you will not be claiming from them for the accident; OR if you do not have insurance provide an affidavit of non-insurance done by the registered owner of the vehicle.
  • Supply 2 quotations for the damage of the vehicle.

OPTIONAL:

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: _________________________

Street/Intersection: _________________________________________________________________

Suburb/Town: _____________________________________________________________________

Vehicles involved: __________________________________________________________________

 Where were you at the time of the accident: _____________________________________________

Accident Description:

Please give us the detailed description of how the accident happened:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Accident Sketch:

Please draw a sketch showing the accident and indicate where you were at the time of the accident:

 

 

 

 

 

  

SIGNITURE: _________________________________ Date: ________________________________________