LIABILITY CLAIM FORM

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 documentation and information requested on the claim form.

Please quote the claim number on each page.

A third party claim is not an insurance claim and is not dealt with in terms of contractual arrangement, but rather a claim
that will be dealt with in terms of the law. A claim against an OUTsurance client’s facility can take up to 6 weeks to finalise
and we need to inform you the follow up responsibility lies with you.

Every third party claim will be dealt with in terms of its own merits. The merits and quantum will be determined by applying
fair legal principles.

Your documents must be forwarded to:

Fax: 012 673 4659 or
E-mail: newliabilityclaims@out.co.za

PERSONAL INFORMATION

CLIENT DETAILS

Claim number: ____________________________________________________________________

Client: ___________________________________________________________________________
Who was the driver of our vehicle: _____________________________________________________
What is the ID number of our driver: ____________________________________________________

THIRD PARTY DETAILS

Full names of the registered owner of the vehicle: _________________________________________

Home tel: ________________________________________________________________________
Work tel: _________________________________________________________________________
Cell number: ______________________________________________________________________
E-mail: ___________________________________________________________________________
Fax number: ______________________________________________________________________
Who will be the contact/liaison on your side for the purpose of this claim?
_________________________________________________________________________________

OUTsurance Insurance Company Limited. Reg. No. 1994/010719/06. An Authorised Financial Services Provider (FSP 896)
Directors: L Dippenaar (Chairman), DH Matthee (Chief Executive Officer), P Cooper, R Pretorius, GL Marx, A Hedding, K Pillay, J Madavo,
ET Moabi, B, Hanise, ME Ramathe, HL Bosman, MC Visser, RSM Ndlovu, Company Secretary: M Ehlert
CONTACT DETAILS OF THE LIAISON IF THIS IS NOT THE REGISTERED OWNER

Name: ___________________________________________________________________________
Home tel: ________________________________________________________________________
Work tel: _________________________________________________________________________
Cell number: ______________________________________________________________________
E-mail: __________________________________________________________________________
Fax number: _____________________________________________________________________

VEHICLE INFORMATION

It is very important that we have a full detailed description of your vehicle.

Registration number of your vehicle: ___________________________________________________
What is the make of your vehicle: _____________________________________________________
What is the year model of your vehicle: ________________________________________________
Is your vehicle driveable (yes/no): ____________________________________________________
Provide the address where the vehicle is located:
_________________________________________________________________________________
Was your vehicle towed from the scene (yes/no): _________________________________________
If yes, please advise us where your vehicle was towed to (name and address):
_________________________________________________________________________________

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 pay for storage, security
and administration costs.
When a decision is made to pay the claim we will compensate you for only the reasonable first towing costs.
We do not pay for car hire costs, unless the vehicle is used for business purposes to generate an income and proof will be
required

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REQUIRED DOCUMENTATION

DOCUMENTATION THAT WE NEED FROM YOU

1. Vehicle registration document (not the motor license certificate). Please note that the reason why we require a copy
of your vehicle registration document is to prove ownership in the event that you are claiming for damages to a
vehicle;
2. ID copy of registered owner;
3. Driver’s license of the driver on the day of the accident;
4. Sketch and description of how the accident happened (to be done by the accident driver);
5. If you have insurance, please provide a letter from your 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;

Once your documents have been correctly submitted and your claim allocated to one of our legal consultants, we will be in
contact with you to arrange to have your vehicle booked in to one of our drive in centres to allow us to determine the extent
and value of the damages sustained to your vehicle.

INSURANCE LETTER

The letter from your insurance company must have the following information:
 Policy number and name of policy holder;
 Vehicle make and registration number;
 Date of the accident;
 Statement that you will not be claiming from them;
 Confirmation of your scope of cover and excess.

AFFIDAVIT OF NON INSURANCE

The affidavit should be worded as follows and it should be done by the registered owner of the vehicle:

I (name and Surname), ID number; of address hereby state that under oath that my vehicle with registration numbers was
involved in a motor vehicle collision on date.

This vehicle was not insured at the time of the accident.

WITNESS STATEMENT

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If you have an independent witness, not a passenger in your vehicle, please advise your witness to complete the witness
form below. The witness statement is optional.

WITNESS DETAILS

Full names: _______________________________________________________________________

Home address: ____________________________________________________________________
Business address: _________________________________________________________________
Home tel: ________________________________________________________________________
Work tel: _________________________________________________________________________
Cell number: ______________________________________________________________________
E-mail: ___________________________________________________________________________

WHEN, WHERE AND HOW DID THE ACCIDENT HAPPEN

Date of the accident: _______________________________________________________________

Time: ___________________________________________________________________________
Weather conditions: _______________________________________________________________
Visibility: ________________________________________________________________________
Street/Intersection: ________________________________________________________________
Suburb/Town: ____________________________________________________________________
Vehicles involved: _________________________________________________________________
Did you have a clear view of the accident: ______________________________________________
Where were you at the time of the accident: ____________________________________________
Were there any other witnesses on the accident scene? If so, please give us their names and contact details:
_________________________________________________________________________

ACCIDENT DESCRIPTION

Please give us a detailed description of how the accident occurred:

________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

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________________________________________________________________________________________________
___________________________

ACCIDENT SKETCH

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

Signature: ________________________________________________________________________
Date: ____________________________________________________________________________

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