PUBLIC LIABILITY ACCIDENT REPORT FORM

OPENBARE AANSPREEKLIKHEID ONGELUK VERSLAGVORM

INSURED / VERSEKERDE

DESCRIPTION OF THE ACCIDENT / BESKRYWING VAN DIE ONGELUK

WITNESSES / GETUIES

POLICE / POLISIE

PROPERTY DAMAGE / EIENDOM SKADE

PERSONAL INJURIES / PERSOONLIKE BESERINGS

RELATIONSHIP / VERWANTSKAP

CLAIM / EIS

In order for us to settle your claim in terms of ELECTRONIC FUNDS TRANSFER please provide the following EFT (Banking) details / Ten einde ons in staat te stel om u eis ooreenkomstig ELEKTRONIESE FONDS OORPLASING te betaal, meld asseblief die volgende EFO (Bankwese) besonderhede:

Please upload the needed documentation to support your claim here.

Laai asseblief u nodige dokumentasie hier op om u eis te staaf.

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