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Personal Details form

. PERSONAL AND ACCIDENT DETAILS A INJURED PERSON’S DETAILS Medical Aid: ................................................................ Membership No. ........................................................... 1. Full name of person injured: ……………………......................................................................................................................... 2. Residential address : ...................................................................................................................................................................... ......................................................................................................................................................................................................... 3. Postal address: ............................................................................................................................Fax No: (......).......................... 4. Home tel number : (........) ............................ Work tel number : (.......) ......................... Cell No : ............................... 5. E mail address (If you want correspondence to be sent to you electronically) : ............................................................................. 6. Identity number :.................................... Date of Birth : ................................... Citizenship : .............................................. 7. Occupation : ............................................... Employers name and address : ............................................................................ ........................................................................................................................................................................................................ 8. Name, address and tel no. of usual house doctor : ......................................................................................................................... 9. Were you injured in the course of your employment when the accident occurred : Yes / No If yes, was a Workmans Compensation Claim submitted: yes/no/do not know Reference number if known .................... 10. Were you an employee of the driver or the owner of the motor vehicle in which you were travelling? Yes/No 11. Did you have any other injuries or sickness at any time before this accident: yes/no Details ................................................. ........................................................................................................................................................................................................ 12 (a) Marital status at time of accident: never married o married o divorced o widowed o (b) If married: in community of property o out of community of property o customary union o B IF THE INJURED PERSON IS UNDER 21 YEARS, DETAILS OF PARENT / NATURAL GUARDIAN 1. Full name of parent / guardian :........................................................................................................................................................ 2. Relationship to injured person : natural father / natural mother / adoptive father / adoptive mother / other (specify)....................... 3. Address of parent/ guardian : ........................................................................................................................................................... 4. Home tel no : (.........) ............................ Work tel no : (........) ........................ Cell no : ........................................ 5. E mail address (If you want correspondence to be sent to you electronically) : ............................................................................. 6. Identity number of parent / guardian ; .................................... Date of Birth : ......................... Citizenship : .............................. C ACCIDENT DETAILS 1. Date of accident : .......................... Time: ............. Street / Road name :................................................................................. 2. Police station to which accident was reported :................................................. Case number : ................................................ 3. Description of how accident occurred: .....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................……………….. 4. Witnesses names, addresses and telephone numbers................................................................................................................... .......................................................................................................................................................................................................... .......................................................................................................................................................................................................... 5. Rough sketch of how accident occurred : SEE ANNEXURE “A” - 2 - D DETAILS OF VEHICLE IN WHICH INJURED PERSON WAS DRIVING OR A PASSENGER 1. Were you the driver or a passenger : .................................................. 2. Registration number : ................................... Make : ....................................... Colour : ..................................................... 3. Name of the driver : ............................................. Address of the driver : .................................................................................. .................................................................................................................................. Tel no of driver : (.......) ...................... 4. Name of the owner : ............................................. Address of the owner : ................................................................................ .................................................................................................................................. Tel no of owner : (.......) ..................... E DETAILS OF VEHICLE WHICH CAUSED THE ACCIDENT 1. Did the vehicle mentioned in section D above, cause the accident : Yes / No / Partly If another vehicle caused the accident either wholly or partly, then complete the rest of this paragraph 2. Registration number of vehicle which caused the accident : ............................ Make : ........................ Colour : .................. 3. Drivers name : ........................................................ Address of driver : ........................................................................................ ...................................................................................................................................... Tel no of driver : (.....) .......................... 4. Owners name : ...................................................... Address of owner : ....................................................................................... ..................................................................................................................................... Tel no of owner : (......) ....................... F PEDESTRIANS 1. If you were not travelling in one of the vehicles mentioned in paragraphs D or E above, were you a pedestrian? Yes / No 2. What colour clothing were you wearing (describe the clothing): ................................................................................................ .................................................................................................................................................................................................. .................................................................................................................................................................................................. G OTHER VEHICLES INVOLVED (If any) C D 1. Registration no : ................................................................................ ................................................................................ 2. Make: ................................................................................ ............................................................................... 3. Drivers name : ................................................................................ ............................................................................... 4. Drivers address : .............................................................................. ............................................................................ 5. Owners name: ............................................................................... ............................................................................. 6. Owners address: ............................................................................... ............................................................................. - 3 - H INJURIES AND TREATMENT 1. Description of injuries (Detail all injuries, no matter how small - from broken bones to scratches and bruises!) :........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 2. What is the name of the first doctor/s who treated you (if in a hospital, give the hospital name too): ......................................................................................................................................................................................................... 3. The names of all other doctors who treated you : ........................................................................................................................... .................................................................................................................................................................................................. 4. Name of hospitals attended :............................................. from ................... to ..................... and from ............... to ............ :........................................... from ................... to ..................... and from .............. to ............. 5. Hospital reference numbers : (if known) ......................................................................................................................................... I OTHER DETAILS (If there are any additional details which you feel need be noted, please quote with reference to the relevant paragraph) ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Enclose copy of front page of ID document, showing photograph and ID number - 4 - ANNEXURE"A" ROUGH SKETCH ONLY Lanes, positions of vehicles, road markings etc. are for illustrative purposes only, are not to scale and may not be totally accurate.

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