Welcome to the Pogir Group, we have over 55 years of expertise.

011 879 7200/7250
info@pogir.co.za

St Andrews Office Park
39 Wordsworth Avenue, St Andrews.

08:00 – 16:30
Monday to Friday

We make it our business to make it personal. Giving you lasting peace of mind.

Motor Accident Claims Form

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SECTION 1: INSURED

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SECTION 2: VEHICLE

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Section 3: DAMAGE

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Is your vehicle under warranty

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Is your vehicle under a motor plan?

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Section 4: DRIVER

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Was he/she driving with permission?

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Has license ever been endorsed?

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Has he/she any physical defects?

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Section 5: Passengers (insured vehicle)

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  • - Injury -
  • Yes
  • No
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  • - Injury -
  • Yes
  • No
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  • - Injury -
  • Yes
  • No
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Section 6: Third Party (damage to other vehicles/ property)

NB: Please notify the Insurers immediately if you become aware of any impending prosecution, inquest or demand!

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  • Third Party Passenger Injury:
  • Yes
  • No
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Section 7: Accident

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Speed traveling

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Was the drive tested for alcohol or drugs?

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Road surface

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I / we declare that to the best of my/our knowledge the above information is true in every aspect.


NB I acknowledge that should I elect to use a non-manufacturer approved repairer I release Pogo Group from any liability which could arise as a result of any defective workmanship. I acknowledge further that I may lose my manufacturer’s warranty and or maintenance plan that may exist on my vehicle.

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Driver Signature
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Insured Signature
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