Claimant intake
Loss of support

Before we begin

This questionnaire records the particulars of the person who died, of everyone who depended on them, and of the accident, so that Dr Pretorius Inc can prepare a report in connection with a claim for loss of support. You may complete the sections in any order and return to finish later.

We are sorry for your loss. Some of what follows is difficult to write down. Answer what you can, leave anything you are unsure of, and the practice will help you with the rest.

Please read this first

Sending this form does not mean your matter has been accepted. Dr Pretorius Inc will consider what you provide and will contact you. Completing this form does not create a doctor–patient relationship, and it does not oblige Dr Pretorius Inc to accept or report on your matter.

Dr Pretorius Inc will confirm in writing once your matter has been accepted. Until then, please do not assume any assessment is underway. Claims against the Road Accident Fund have strict time limits, and those limits keep running whether or not you have sent this form.

Please have ready
01The death certificate and the identity document of the person who died
02Your own identity document, and one for every dependant
03A marriage certificate, and the birth certificate of each child
04The accident reference and police case number
05What the deceased earned — payslips, employers and dates
06The funeral account, and any policy that paid out
Indemnity & POPIA consent

The information you provide is supplied directly to Dr Pretorius Inc for the purpose of preparing a report in connection with a claim for loss of support. It is not used for anything else.

Your answers stay on this device until you press send. They are not stored on this website, and nothing you type is saved anywhere until the completed form is sent.

Your information will not be sold, published or shared with any third party except where it is necessary for the claim or where the law requires it. It will be handled confidentially, kept only for as long as it is needed, and used solely for the purpose described above.

This form asks about other people — the person who died, and each dependant. By continuing you confirm that you are entitled to give their details for this purpose, and that you will tell any adult dependant that you have done so.

Cause of death, medical treatment and the ethnic group of a dependant are special personal information under POPIA. They are asked because a loss of support claim and the actuarial calculation behind it cannot be made without them. You may leave any of those questions blank, and you may ask at any time to see, correct or delete what you have sent.

By continuing you confirm that the information you provide is given freely and voluntarily, and that it is true and correct to the best of your knowledge.

Read the full privacy notice and terms of use. They open in a new tab so you do not lose what you have entered.