MOTOR THEFT CLAIM FORM by oqp13905

VIEWS: 5 PAGES: 2

									MOTOR THEFT CLAIM FORM

   Insurer
   Company Name
   Claim Number
   Policy Number

   Insured
   Surname & Initials
   or Company Name
   Company
   Registration No.
   Identity number
   VAT number
   Occupation or
   business
   Physical address

   Email address
   Postal address

   Telephone numbers    Business

                        Home
   Vehicle
   Make
   Model
   Year
   Registration No.
   Kilometers
   completed
   Vehicle
   identification
   Number
   Chassis number
   Engine number
   Exterior colour
   Interior colour
   Finance Company
   Name
   Branch
   Account number
   Type of agreement
   Outstanding amount


                                   1
MOTOR THEFT CLAIM FORM

     Owner
     Name
     Identity Number

     Theft
     Date
     Time
     Place
     Police station
     Reference number
     Date reported
     Reported by
     Was the vehicle
     locked? If not, give
     reasons
     Details of stolen
     accessories (Please
     attach invoices)
     Are these seperately
     insured?
     Details of Anti-        Make
     theft/vehicle           Fitted by
     recovery device         Date
     details                                         Please attach proof of device

     Details of window       Number
     markings
                             Applied
                             by whom
     Details of scratches,
     dents, defects

     Details of other
     features which
     would assist
     identification
     Please attach the vehicle keys, a copy of the registration certificate, and the last service invoice.
I/We hereby declare the foregoing particulars to be true in every respect.

__________________________                                                       __________________________
Signature of Insured                                                             Capacity

__________________________
Date/Datum




                                                             2

								
To top