MVA Main Claim Form March 2008

8/14/2019 MVA Main Claim Form March 2008

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Notes:

a) Readtheheadingofeachsectionandllinifrequired.Section9mustbesignedbeforeaCommissionerofOaths.

b) AnyMVAFundorNampostofcialcanassistyoutollinthisform.

c) Notethatitisacriminaloffencetostatefalseinformationorwithholdinformationrequiredifsuchinformationiswithintheknowledgeofthepersonllinginthisform.

d) Aparent,guardianorcuratorshouldllintheformforachild.

SECTION1PersonaldetailsoftheClaimant

a) Surname

b) First Names

c) Identication Number )) Place tick Male Female

e) Date of birth

f) Place of birth

g) Nationality

h) Status (Place tick ) Marrie Single Divorced Widowedi) Resiential aress

j) Postal address

k) Phone Numbers W H Cell

l) Iftheclaimantisclaimingonbehalfofanotherperson,he/sheshouldstate:

(i) Relationship of claimant to such person:

(ii)Name and address of person on whose behalfcompensation is being claimed:

(iii) Identity / Passport No. of such person:

PleaseattachacertiedcopyofI.D.orpassport.Intheeventofaclaimforlossofsupportoronbehalfofanotherperson,photocopiesofrelevantmarriageand/orfullbirthcerticate,asthecasemaybe,shouldaccompanythisform.

Kindlyprovidedetailsoftwocontactpersons

m) Name

Contact details

n) Name

Contact details

ClaimFormMVAF1


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SECTION3DetailsoftheDeceased

Fillinonlyifclaimisfornanciallossofsupport;reimbursementoffuneralexpensesand/orcostsofpastmedicaltreatmentfordeceased

DetailsoftheDeceasedonlya) Surname

b) First names

c) Identication number

) Date of injury e) Date of death

f) Name of clinic/hospital where rst treatedg) Name of doctor who rst treated deceasedh) Was deceased ill prior to death? YES NO What illness?

i) Place of death

j)What was the relationship ofthe deceased to the claimant?Place a tick

Spouse Father Mother Son Daughter

If other please specify -

k) (i) Employed or self employed? Place a tick Employed Self-employed

(ii) Trade or occupation. State sector, if self-employedl) Name of employer

(i) Address of employer

(ii) Phone number of employer

(iii) Earnings of deceased per month(iv) State address from where the

deceased operated

(v) Earnings per month

m) Was deceased on duty at time of accident?n) State names of all the

deceased dependents,incluing claimant

Name(s) of dependent(s) Date of birth

Intheeventofclaimforlossofsupport,pleaseprovidecertiedcopiesofthedeceasedsthreemostrecentpayslips,I.D.orpassport.Intheeventofclaimforpastmedicalcosts,pleaseprovideoriginalinvoices.

SECTION2DetailsofClaim

Placeatickforthebenetsbeingclaimed Estimatedloss(N$)

a) Costs of past medical treatment

b) Costs of future medical treatment

c) Reimbursement of past income lost

) Reimbursement of future income to be loste) Financial support lost as a result of death of person (only for dependents)

f) Reimbursement of funeral grant

g) Injury grant


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SECTION5MitigationofLoss

Givedetailsofotherpaymentsclaimantentitledto

Placeatick IfYesgivedetails,e.g.,amountpayablepermonthorcashamount

a) Workmans Compensation NO YES

b) Social Security Support benets NO YES

c) Social Security Death benets NO YES

) Meical ai NO YES

e) Any other grant from Government NO YES

SECTION4DetailsofIncome

Fillinifclaimisforreimbursementofincomelost

a) Trade or occupation

b)Employed or self

employed? Place a tickEmployed Self employed

c)If employed, state name ofemployer

) Address of employer

e) Phone number of employer

f) Earnings per monthg) Income from own business

h) If self employed, state occupation or sector(i) State address from where you

operate

i) Period of employment

j) Period of not working due to injuryk) Total of income lost N$

l)Details of any other income or earningswhich is not part of the claimants salary

N$

Kindlyattachaletterfromyouremployerindicatingtheperiodinwhichincomewaslost,certiedcopiesofmedicalcerticateandtwomostrecentpayslipsprovingtheloss.


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SECTION6PoliceReport

Tobecompletedbythestationcommanderorhis/herdesignateatthestationwheretheaccidentwasreportedortheMVAFundinvestigatorwhoattendedthescene

a) Rank and name of police ofcer/MVA Fund investigator

b) Force number c) Name of police station) Contact number

e) Was this accident reported? Place a tick YES NO f) Date of report

g) Who reported? h) Place of accidenti) Accient ate

an time

j) Accident Report Numberor CR Number

k) Listthenumberofvehiclesandname(s)ofdriversinvolvedintheaccident

Vehicle type Registration No. Name of driver ID No.

i)

ii)

iii)

iv)

l) Statenamesofpassengersandvehicleinwhichtheytravelled

Passenger Vehicle Injured/ Deceased(Place a tick)

Placeatick on all documentation attached to the claim formonalldocumentationattachedtotheclaimform

m) Accident Report Form(Pol 66) attached

YES NO Claimants Statement YES NO

Photographs YES NO Sketch Plan YES NO

Vehicle inspection done YES NO Post Mortem Report YES NO

Blood alcohol report YES NO Inquest YES NO

Statements of witnesses YES NO Drivers warning statement YES NO

If none of the above documents are available, please inform us in writing

n) Was the deceased identied in section 3 of this form involved in the accident? YES NO

Kindlyensurethatalldocumentationmentionedaboveisattachedtotheclaimformwhereapplicable.Ifanyoneoftheabove-mentioneddocumentsisnotavailable,pleaseinformtheFundinwriting


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o) Give summary of accident facts

Police Stamp Signed ..........................................................................

Name ............................................................................

SECTION7MedicalReport

Thisreportmustbecompletedbythemedicalpractitionerwhotreatedtheinjuredperson unlessthatmedicalpractitionerisnotavailable.

Incaseswherethemedicalpractitionerisnotavailable,aregisteredmedicalpractitionerwhohas

acquaintedhim/herselfwiththecaseshouldcompletethissection

a) Name of medical practitioner Practice No.

b) Are you the rst medical practitioner to treat the injured person? Place a tick YES NOc) If no, state name of medical

practitioner who rst treated the

injured person

Practice No.

) Name of house medical practitioner Practice No

e) Full name of injured person

f) Date(s) of examination Place

Pleaseplaceatickinboxbelowg) Was injured person(s) blood tested for alcohol level? YES NO

h) If yes, is there a report available? YES NO

i) Kindlyindicatetheseverityofinjuriesbelow,withatickintheboxalongsiderelevantinjury(ies)N.B. For convenience, this report can be attached to the form as a seperate annexure

Hea Chest Neck Abdomen Back Upper limbs Lower limbs Pelvis

Minor

Fairly severe

Severe


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j) Doctor to provide full details of the nature of the injuries and any other comment and noteshe/she may deem appropriate (e.g. fractured ribs with haemothorax, compound fracture left tibia,disgurement etc.)

k) State treatment given to date:

l) At the time of your rst examination,Was the patient conscious?Please place a tick

YES NO

If no, please provide Glasgow Coma Scale reading

m) Did the injured person require hospitalization? YES NO If so, state periodn) Was the injured person booked off? YES NO If so, state periodo) Did the patient require surgery? YES NO If yes, state type

p) Do you expect permanent disability? YES NO Specify


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q) If yes to questions (m), (n), (p) above, please identify briey

r) State medication patient was ons) Is future medical treatment foreseen? YES NO

(i) If yes, what will be the probable nature of treatment be in respect of which injuries?

(ii) Expected date thereof:(iii) Expected duration thereof:

(iv) Estimated cost thereof (if possible) N$(v) Is hospitalization foreseen in connection with the future treatment

referred to in (i) aboveYES NO

t) If yes, state:

(i) Expected date of such hospitalization

(ii) Expected duration thereof

Signature .........................................................................................

Qualication .............................................................. Name................................................................................................

Date..................................................

Doctorsorhospitalstamp

CopiesofallmedicalrecordsfromdateofrsttreatmentMUSTbeattached.


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Section9ClaimantsAfdavit

Iherebydeclarethatthedeponenthassworntoandsignedthisstatementinmypresenceat............................................................onthedayof.............................20....andhe/shedeclared

asfollows:thatthefactshereincontainedfallwithinhis/herpersonalknowledgeandthathe/sheunderstandsthecontentshereof;thathe/shehasnoobjectiontotakingtheoath;thathe/sheregards

theoathasbindingonhis/herconscienceandhasdeclaredasfollows:

IswearthatthecontentsofthisSwornAfdavitaretrueandcorrect,sohelpmeGod.

Signed ......................................................... ClaimantsName

Date ............................................................

SWORNBEFOREME

Commissioners stamp Signed ......................................................... CommissionerofOaths/Capacity

Notethatiftheclaimantisunderlegaldisability,thisformshouldbesignedbytheclaimantsguardian,curatororcustodian.

Section8BankingDetails

Ifyouwantyourmoneytobedepositeddirectlyintoyourbankaccount,pleasecompletethissection

I, _______________________________________________________________________, the undersigned, state:

1. I am the holder of a bank account with the following details:

Account Holder Name:_______________________________ Account number:___________________

Account type (savings/cheque/etc):______________________Bank:________________________Branch:_______________ Branch code:______________

2. I hereby request that the cheque be deposited into the above bank account.

3. I accept the risk of any loss that I may suffer as a result of the fact that the cheque is deposited into this bankaccount, and indemnify the MVA Fund of all or any loss or damage, whether direct or indirect, that might arise as aresult of the cheque being deposited.

...................................................................... .............................................................Claimant Date

Pleaseensurethattheabovebankdetailsarecorrect.

Documents

MVA Main Claim Form March 2008