Claim Assessment Form

To find out if you have a claim, please fill in the following form and one of our staff members will get back to you.

*NOTE: WE ARE NOT THE ROAD ACCIDENT FUND. WE ARE A FIRM OF ATTORNEYS WHO WILL CLAIM FROM THE ROAD ACCIDENT FUND ON YOUR BEHALF.

Assessment reports will be emailed from website@liebenberggoedhalsinc.co.za to LandGAtterneysInc@gmail.com

Full Name:

ID Number:

Contact Number:

Email Address:

Residential Address:

Date of Accident:

Time of Accident:

Location of Accident:

Who Was Hurt:

Was the accident reported to SAPS?

What Was Your Involvement:

Nature of Injuries:

Who Is The Claim For:

Any loss of income or medical expenses?

*NOTE: WE ARE NOT THE ROAD ACCIDENT FUND. WE ARE A LAW FIRM DEDICATED TO HELPING YOU CLAIM ON YOUR BEHALF.