City of Johannesburg Johannesburg Roads Agency 66 Pixley Seme Street (previously Sauer Str.) Cnr. Rahima Moosa Street (previously Jeppe Str.) Johannesburg 2001

Contact person Telephone no Email address

: : :

P/Bag X70 Braamfontein South Africa 2017

Tel +27(0) 11 298 5000 Fax +27(0) 11 298 5178 www.jra.org.za www.joburg.org.za

Frans Nkosi 011 298 5168 / 011 491 5734 [email protected]

In addition to completing the claim form, attach the following documents: The following information is submitted to the JRA on the express understanding that same is submitted for the purpose of enabling the JRA to consider and process claim against it will be processed and stored in terms of the insures and the City of Johannesburg. 1.) 2.) 3.) 4.) 5.) 6.) 7.)

Police affidavit Copy of driver’s license of the claimant Vehicle registration documents Copy of ID Photos of the damage to the car 3 Quotations or invoice/proof of pay Letter from insurance company confirming that the claim was not logged to own insurance/Affidavit of noninsurance. 8.) Doctors report if there is personal injury Terms and Conditions 1. Completed claim form must be submitted. 2. All the above documents must be attached to the claim form or the claim will not be considered. It is your duty to ensure that all supporting documents as requested above are submitted with your claim form. Kindly take notice that the JRA will not contact a claimant to request additional documentation, if your claim form is not accompanied by all the above supporting documents, your claim will be regarded as not submitted. 3. Claims must be submitted by 13h00, and claims submitted after 13h00 noon will be treated as submitted the following business day. 4. Please only email or fax the form and do not do both as this only delay the process. No hand delivered claims will be accepted. 5. If you do not receive acknowledgement of receipt within 3 business days with a reference number, please contact our offices either via the following email address [email protected] or via telephone. Kindly allow for 30 business days from the date of receipt of acknowledgement before following up on the progress of your claim. 6. Please remember to sign the claim form and attach all required documents. Failure to do so will result in your claim being rejected. Please only email the form .If you do not receive acknowledgement of receipt within 3 days with a reference number please contact our offices via the mail or via telephone.

Directors: Chairman: J Manche, Managing Director: Vacant, CFO: G Mbatha Non-Executive Directors: M Ramasia, J Maina, A Torres, N Msezane, E Ngomane, L Mashamaite, L Nxumalo, H Mashele, Company Secretary: K Mills Registration No. 2000/028993/07

Please remember to sign the claim form and attach all required documents. Failure to do so will result in your claim being rejected. Name Naam Insurer Versekereer Policy No Polis Nmr Eis nmr

Name

Naam

Email Address

E-pos adres

Address and phone no

Adres & tel nommer

Business or occupation Date and Time

Ondermerring of beroep Datum en Tyd

Place and streets where incident occurred

Plek en straat waar voorval plass gevind het

Name, Address & Tel No

1.

2.

Naam, adres en tel.nmr

Indien by polisie aangemeld, meld betrokke kantoor en verywysings nommer

Name and address of owner

Naam en adres van eienaar

Full Description

Vol Beskrywing

Eiendomska de

If reported to police, state which station and reference number

Polisie

Police

Witnesses

Getuies

Property Damage

Versekerde

Insured

Claim No

Relationship

Name, address and age of injured persons

1.

2.

Naam, adres en ouderdom van beseerdes

Details of injuries

1.

2.

Besonderhede van beserings

Indien enige van die bogonoemde persone ‘n werknemer, ‘n huurder of ‘n familielied is, meld besonderhede

If a claim has been, or is being made against you, give details and attach any correspondence.

Indien ‘n eis teen u ingestel is, of teen u ingestel word, meld besonderhede en heg alle korrespondensie aan.

Eis

If any person named above is in your service, or your tenant, or related to you, give full details

Ver-wantekap

Claim

van verlies of skade

Persoonlike beserings

Personal Injuries Injuries

of loss or damage

Beskryf presies hoe die voorval plaas gevind het.

Beskrywing van voorval

Description of incident

Describe exactly how the incident Occurred

………………………………………………. I/We (ID No…………………………………………………..) declare that to the best of my/our knowledge the above statements are true.

Verklaring

Declaration

……………………………………………… Ek/Ons (ID no………………………………………………….) verklaar dat na my/ons beste wete die bostaande inligting waar is.

___________________________ Insured’s Signature / Verskerede se handtekening

Capacity / Hoedanighed ………………………………………..

______________________________ Date / Datum