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RAF Claim Assessment Form
Complete this form so we can assess your Road Accident Fund (RAF) claim and contact you quickly.
Step 1 of 6
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Name *
Surname *
Telephone (10 digits, no +27) *
Example: 0821234567
Email
Age group *
Select
Under 18
18–25
26–35
36–45
46–55
56–65
66+
Preferred contact method *
Select
WhatsApp
Call
Email
Best time to call *
Select
Morning
Afternoon
Evening
Province where accident happened *
Select
Eastern Cape
Free State
Gauteng
KwaZulu-Natal
Limpopo
Mpumalanga
North West
Northern Cape
Western Cape
Nearest town / suburb *
Date of accident *
Time of accident
Where did it happen? (road/landmark)
Police case number
Was the accident reported to SAPS? *
Select
Yes
No
Not sure
Was the accident within the last 3 years? *
Select
Yes
No
Not sure
Do you have any of these?
Accident report (AR form)
Photos/videos
Hospital/clinic records
Witness contacts
None yet
Do you have witness contact details? *
Select
Yes
No
Type of transport *
Select
Private vehicle
Taxi
Bus
Train
Uber/Bolt
Motorcycle
Pedestrian
Bicycle
Other
Your role at the time *
Select
Driver
Passenger
Pedestrian
Cyclist
Other
Were you the driver? *
Select
Yes
No
Were you alone in the vehicle? *
Select
Yes
No
Not applicable
Accident type *
Select
Single vehicle (lost control)
Collision with another vehicle
Hit-and-run
Vehicle vs pedestrian
Other
Was another vehicle involved? *
Select
Yes
No
Not sure
Do you have the other vehicle’s registration number?
Select
Yes
No
Do you know the other driver’s details?
Select
Yes
No
Was the other vehicle unidentified or did it flee? *
Select
Yes
No
Not sure
Injuries sustained (select all that apply) *
Whiplash/neck injury
Back injury
Shoulder injury
Arm/hand injury
Wrist injury
Hip injury
Leg/knee/ankle injury
Head injury/concussion
Facial/dental injury
Cuts/lacerations
Fractures/broken bones
Internal injuries
Psychological trauma/PTSD
Spinal injury
Burn injuries
Other
Tip: hold Ctrl/Command to select multiple on desktop.
Were you taken to hospital? *
Select
Yes
No
Admitted overnight? *
Select
Yes
No
Do you still have symptoms today? *
Select
Yes
No
Any permanent disability/impairment? *
Select
Yes
No
Not sure
Loss of limb(s) / amputation? *
Select
Yes
No
Scarring or disfigurement? *
Select
Yes
No
Did a doctor diagnose your injuries? *
Select
Yes
No
Do you have medical records? *
Select
Yes
No
Did you have the same injury before this accident? *
Select
Yes
No
Not sure
Pain level today (0–10) *
Can you do normal daily activities? *
Select
Yes
Partially
No
Follow-up treatment (select all that apply)
Physio
Surgery
Rehab
Counselling
None
Highest level of education *
Select
Primary
Some high school
Matric
Certificate
Diploma
Degree
Postgrad
Were you employed at the time of the accident? *
Select
Full-time
Part-time
Self-employed
Unemployed
Student
Employer name
Job title
Approx. monthly income (before accident)
Select
Under R5,000
R5,000 – R9,999
R10,000 – R19,999
R20,000 – R39,999
R40,000 – R59,999
R60,000+
Are you still able to work after the accident? *
Select
Yes fully
Limited duties
Not able to work
Not sure
Did you lose your job because of the accident? *
Select
Yes
No
Not applicable
Did you miss work days? *
Select
0
1–7
8–30
31–90
90+
Were you under the influence (alcohol/drugs/medication)? *
Select
No
Yes
Not sure
Was any other driver under the influence? *
Select
Yes
No
Not sure
Have you already lodged an RAF claim? *
Select
Yes
No
Not sure
Do you already have a lawyer/law firm representing you? *
Select
Yes
No
Law firm name
Are you willing to switch? *
Select
Yes
No
Not sure
Have you signed any documents with another firm? *
Select
Yes
No
Not sure
Have you received any RAF payout offer? *
Select
Yes
No
Who are you completing this form for? *
Select
Myself
Someone else
Relationship to claimant *
Select
Parent/Guardian
Spouse
Relative
Other
Is the claimant a minor (under 18)? *
Select
Yes
No
Are you submitting on behalf of a deceased person? *
Select
Yes
No
Were you financially dependent on the deceased? *
Select
Yes
No
Do you have a death certificate? *
Select
Yes
No
I consent to my information being used to assess my RAF claim and to be contacted (POPIA).
Anything else we should know?
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