MOTOR ACCIDENT CLAIM FORM by Cannabisrapper

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									                                              MOTOR THEFT CLAIM FORM
   INSURER




                     NAME

                     CLAIM NUMBER

                     POLICY NUMBER

                     NAME
   BROKER




                     CLAIM NUMBER



                     COMPANY NAME /
                     SURNAME AND INITIALS



                     COMPANY REGISTRATION
                     NUMBER

                     IDENTITY NUMBER
   INSURED




                     VAT NUMBER

                     OCCUPATION OR BUSINESS

                     PHYSICAL ADDRESS



                     POSTAL ADDRESS



                     TELEPHONE NUMBERS        BUSINESS

                                              HOME

                     MAKE

                     MODEL

                     YEAR

                     REGISTRATION NUMBER
    VEHICLE




                     KILOMETRES COMPLETED

                     VEHICLE IDENTIFICATION
                     NUMBER

                     CHASSIS NUMBER

                     ENGINE NUMBER

                     EXTERIOR COLOUR

                     INTERIOR COLOUR

                     NAME
   COMPANY
   FINANCE




                     BRANCH

                     ACCOUNT NUMBER

                     TYPE OF AGREEMENT

                     OUTSTANDING AMOUNT


                     NAME
   OWNER




                     IDENTITY NUMBER




46f7356b-15ed-4a53-845d-1c3b57c8aa40.doc
                                                         MOTOR THEFT CLAIM FORM


                     DATE

                     TIME

                     PLACE

                     POLICE STATION REPORTED TO

                     CASE NUMBER

                     DATE REPORTED

                     REPORTED BY




                     CIRCUMSTANCES




                     WAS THE VEHICLE LOCKED ?
   THEFT




                     IF NOT, GIVE REASONS



                     DETAILS OF STOLEN
                     ACCESSORIES (PLEASE ATTACH
                     INVOICES) ARE THESE
                     SEPARATELY INSURED ?


                                                        MAKE

                     ANTI-THEFT / VEHICLES              FITTED BY
                     RECOVERY DEVICE DETAILS
                                                        DATE

                                                                                        PLEASE ATTACH PROOF OF DEVICE

                     DETAILS OF WINDOW MARKINGS         NUMBER

                                                        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 NOTICE

   BANKING           BANK……………………………………………………………………………….                      BRANCH …………………………………………………………             BRANCH CODE ……………………………….
   DETAILS
                     ACCOUNT NAME ………………………………………….…………….                     ACCOUNT NO …………………………………………….             TYPE OF ACCOUNT ……………………..



I/ We hereby declare the foregoing particulars to be true in every respect.

……………………………………………………………………………..                        ……………………………………………………………………………..                ……………………………………………………………….
Signature of Insured                                   Capacity                                             Date




46f7356b-15ed-4a53-845d-1c3b57c8aa40.doc

								
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