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RAF Info Sheet

Information Sheet
Full Names*
First Middle Last
ID Number*
Work Number
Mobile Number*
Marital Status*
Type of Marriage?
Physical Address*
Street Address Address Line 2 City Province Postal Code Country
Is your Physical address the same as Postal?*
Postal Address*
Po Box Address Line 2 City Province Postal Code South Africa
Email
Do you have medical aid?*
Medical Aid Name & Membership Number

eg. Discovery 12345676
Highest Level of Education*
Accident Details
Date of Accident*
DD slash MM slash YYYY
Time of Accident*

: Hours

Minutes
Place of Accident*
Please insert address etc. More detail the better.
Police Station reported at.*
Police reference no.*
Injuries Sustained*
Details
Were you in a car or a pedestrian?
Registration number of Vehicle you were in.
Were you driving?
Name of Owner
First Last
Registration of vehicle you are blaming
What was the make and model of Vehicle?
Owner of above vehicle
First Last
Was owner the driving?
Name of Driver
First Last
Witness details
Witness Name
First Last
Contact number
Email Address
Doctor’s information
Family Doctor Name
Prefix First Last
Contact number
Hospital you were treated?
Doctor who treated you?
Prefix First Last
Hospital Address
Street Address Address Line 2 City Province Postal Code Country
Hospital reference number
When did you consult above Dr?
MM slash DD slash YYYY
Were you admitted to hospital?
Date admitted
DD slash MM slash YYYY
Date discharded
DD slash MM slash YYYY
What date did you return to work?
DD slash MM slash YYYY
Employers Information
Company Name
Occupation
Gross monthly income
Did you lose any income due to accident?
Description of the Accident:
How would you like to describe the accident
Detailed description
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Max. file size: 128 MB.
Please note that sending you this information sheet for your completion does not signify that we are your attorneys or that we have agreed to take on your case. We will consider the information that you supplied to us and thereafter make a decision as to whether or not to take on your case. If we elect to take on your case we will, within 14 days of receipt of the documents, send you a file number in your matter and you will from then on receive e-mails from us every two weeks updating you as to the status of your case. If you do not receive a file number or an e-mail every two weeks, you can assume that you are not a client of ours and if you feel that we may have incorrectly taken on your case, you are welcome to then contact us. We must point out that there are strict time limits when doing Road Accident Fund cases and we cannot take on cases with too short a time before the case prescribes and for that reason it is also important that you not only let us have the information timeously, but if you have not heard from us within a week that you do take the onus to follow up with us.
Consent*
I agree to the above.
Signature*

63118

Contact Information

Form

RAF Info Sheet

Information Sheet

Accident Details

Details

Witness details

Doctor’s information

Employers Information

Description of the Accident: