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Witness Forms
THIRD PARTY RESPONSE FORM
CLAIM NUMBER :
OUR CLIENT :
1. I am insured. My Insurance Company/Broker is: ____________________________
Contact person: _________________________________________________________
Telephone number: ______________________________________________________
My Policy / Claim number: _________________________________________________
2. No, I am not insured but I accept liability and I am willing to settle the debt by way of monthly installments.
I can afford R ____________________ per month.
My contact details are (H) _____________________________
(W)_____________________________
3. I do not feel that I was negligent. Herewith my description and sketch of the accident:
Sketch:
Signed:______________________________________
Date: _______________________________________
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