| 1. |
Claimant |
|
(a) |
- Full name and
residential address
- Citizenship
- Identity/Passport
Number
- Telephone Number
(Home)
- Telephone Number
(Work)
|
|
(b) |
If
the Claimant is claiming compensation on behalf of a
person other than himself /herself (i.e. Father claiming
on behalf of minor child), state:
- Capacity
in which Claimant is acting
- Name
and address of person on whose behalf compensation is
being claimed
- Identity/Passport
number of such person
- Relationship
of Claimant to such person
- Furthermore
photocopies of relevant marriage and/or birth
certificates must be provided
|
| 2. |
Particulars
of Motor Vehicle which caused the loss |
|
(a) |
Registration
letters and numbers and make |
|
(b) |
Name
and address of owner |
|
(c) |
Name
and address of driver at time of accident |
|
(d) |
If the
motor vehicle which caused the accident drove away and is
unidentified, details of efforts made to establish the
identity of the owner or driver of the vehicle |
| 3. |
Particulars
of accident |
|
(a) |
Date
and time |
|
(b) |
Place |
|
(c) |
Police
station at which reported and police reference number
(if known) |
|
(d) |
Rough
sketch of the scene of the accident |
| 4. |
Particulars
of any other vehicle involved in accident |
|
(a) |
Registration
letters and numbers: |
|
(b) |
- Name of owner
- Address
- Occupation
|
|
(c) |
- Name of Driver at time
of accident
- Address
|
| 5. |
Particulars
of person in respect of whose bodily injury or death
compensation is claimed |
|
(a) |
Full
name and address |
|
(b) |
Identity/Passport
Number |
|
(c) |
Sex |
|
(d) |
Date
of Birth |
|
(e) |
Race |
|
(f) |
Marital
status at date of accident |
|
(g) |
Marriage
regime |
|
(h) |
Business/Occupation |
|
(i) |
At
the time of the accident was he traveling in one of the
vehicle described in paragraph 2 or 4 |
|
(j) |
If
yes, state:
- Registration letters
and numbers of vehicle
- Whether a passenger or
drive
|
|
(k) |
If
he/she was not traveling as a passenger or driver in one
of the vehicles described:
- What
was his/her mode of conveyance
- Was
he/she a pedestrian
|
|
(l) |
Name
and address of usual Medical Practitioner (If any) |
|
(m) |
Name
and address of all Medical Practitioner who attended
him/her after the accident (if known) |
|
(n) |
- At which hospital or
nursing home or other place did he/she receive
treatment after the accident
- For how long did
he/she remain at the said hospital or nursing home
- Was he/she a hospital
patient or a private patient
- Hospital reference
number
|
|
(o) |
Was
he/she suffering from any physical defect prior to the
accident |
|
(p) |
If
yes, give details |
|
(q) |
- Name and address of
employer at date of accident
- Period of his/her
employment
- Nature of work
- Date of resumption of
work
|
|
(r) |
Was
his/she injured or killed in the course of his/her
employment |
|
(s) |
State
his/her income for twelve months immediately preceding the
accident
- From employment
- From any other source
(give details)
|
| 6. |
If
person mentioned in paragraph 5 was fatally injured the
following additional information is required in
respect of such person |
|
(a) |
Place
and where death occurred: |
|
(b) |
Date
of death |
|
(c) |
Is
it known whether an inquest was held |
|
(d) |
If
known, state in which Court and reference number |
|
(e) |
Name
and address of the Executor of the deceased’s estate |
|
(f) |
If
available, provide a copy of the report on the post mortem
examination |
| 7. |
If
person mentioned in paragraph 5 was fatally injured and
compensation is claimed by or on behalf of dependents of
that person the following information is required in
respect of each such dependent |
|
(a) |
Full
name and address |
|
(b) |
Identity/Passport
Number |
|
(c) |
Sex |
|
(d) |
Date
of birth |
|
(e) |
Race |
|
(f) |
Relationship
to deceased person together with copy of the relevant
marriage/birth certificate |
|
(g) |
Marital
status |
|
(h) |
Date
of accident |
|
(i) |
Matrimonial
Regime |
|
(j) |
Business
Occupation; |
|
(k) |
If
he/she suffering from any physical defect |
|
(l) |
If
yes, give full details |
|
(m) |
Name
and address of employer at date of accident and how long
employed by such employer |
|
(n) |
State
his/her income for twelve months immediately preceding the
accident:
- From
employment
- From
any other source
|
|
(o) |
Details
and amounts of any inheritance received from estate of the
deceased |
