Bryte RPA Motor Claim Form 1Start2Insured3Vehicle/Damage4Driver5Passengers (Insured Vehicle)6Other Party7Independent Witnesses8Accident Details 9Payment method10Declaration Type of loss: Motor Accident Motor Theft Motor Personal Accident Broker/AgentClaim numberPolicy numberEmail Please enter your email if you would like a copy. InsuredClaim numberPolicy numberCompany name/Surname and initialsCompany registration numberIdentity numberVAT numberBusiness or occupationPhysical addressPostal addressTelephone numbersBusinessCellHome VehicleMakePeculiar identification marks e.g. dents and stickersModelYearPre-existing damageRegistration numberKilometres completedVehicle identification number (VIN)Chassis numberEngine numberState if subject to hire purchase, credit or leasing agreementIf yes, name, address and account number of finance companyDamageDamage to own vehicleIndicate old damage on vehicleWhere is the vehicle at present? (state full address)Is the vehicle driveable? Yes No DriverFull nameResidential addressOccupationIdentity numberDriver’s licence - Month and year of expiryDriver’s licence - Date of issue and code issuedState fully the purpose for which vehicle was being usedWas he/she driving with your permission?Was he/she in your employ?Has he/she any motor insurance on own car? If yes, state policy number and companyDetails of any convictions for motoring offencesHas licence ever been endorsed?Has he/she any physical defects?Details of previous accidents Passengers (Insured Vehicle)Passengers in insured vehicleNameResidential addressInjury Add RemoveFor what purposes were they carriedAre they employees? Yes No Other PartyPersonal injuries (other than in insured vehicles)Name of injuredRelationship to accident e.g. driver, passenger etc.Details of injuriesName of hospital if applicable Add RemoveOther vehiclesRegistrationMakeName of owner and driverID numberContact detailsDetails of damageOld damageAddress of owner and driverColour of vehicle Add RemoveProperty other than vehiclesName and address of ownerDetails of damage Add Remove Independent WitnessesName, address and telephone number 1Name, address and telephone number 2 Accident DetailsDate MM slash DD slash YYYY Time Hours : Minutes AM PM AM/PM PlacePolice stationCase numberDate reported MM slash DD slash YYYY Reported byWas the driver tested for alcohol or drugs? Yes No CircumstancesSKETCH OF ACCIDENTPlease show clearly the point of impact and indicate the direction of travel arrows. Give details of any road safety signs or warning signs in the vicinity of scene of accident. Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB. Payment methodYou may select, for added security, payment of any amount due to you directly into a bank account. Please specify the name of the bank, branch, name of account and account number.Name of bankBranchName of accountAccount number DeclarationWe hereby declare the aforegoing particulars to be true in every respect.Signature of driverCapacityDate MM slash DD slash YYYY Signature of insuredCapacityDate DD slash MM slash YYYY Protection of Personal Information Act (POPIA)All personal information collected on this form will be processed in accordance with our privacy statement. https://www.brytesa.com/pdf/Bryte_privacy_statement.pdfSigned atDayMonthYearSignature of policyholder
