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					                                                    MOTOR THEFT CLAIM FORM

                INSURANCE
                COMPANY
                BROKER              SOUTHSURE BROKERS (PTY) LTD
                POLICY NUMBER
  INSURED




                INSURED NAME
                IDENTITY NUMBER
                OCCUPATION
                ADDRESS AND
                (DAY) PHONE NO.
                CONTACT PERSON
                MAKE                        MODEL                           YEAR                   KILOMETRES
                                                                                                   COMPLETED

                REGISTRATION NUMBER                                         DATE OF PURCHASE
                                                                            AND PRICE PAID
                ANTI-THEFT DEVICE   MAKE/                     FITTED BY AND DATE/
                DETAILS
  VEHICLE




                DETAILS OF          NUMBER/                   APPLIED BY WHOM/
                WINDOW
                MARKINGS
                FINANCING           FINANCE CO        TYPE OF             ACCOUNT NO.          AMOUNT
                                                      AGREEMENT
                DETAILS
                IN WHOSE NAME IS
                THE VEHICLE
                REGISTERED?
                (PLEASE ATTACH A
                COPY OF THE
                REGISTRATION
                CERTIFICATE)
                DATE, TIME AND
                PLACE OF THEFT
                WHAT WAS            VEHICLE AND ACCESSORIES                             ACCESSORIES ONLY
                STOLEN?
                (TICK RELEVANT
                BOX)

                DETAILS OF STOLEN                                                                               )
                   ACCESSORIES
                 (PLEASE ATTACH
                    INVOICES)
THEFT DETAILS




                POLICE STATION
                AND REFERENCE
                NO.



                 CIRCUMSTANCES
                    OF THEFT




                WAS THE VEHICLE
                LOCKED?




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                                                     CHASSIS NO.                               ENGINE NO.
                                                     COMPONENT NUMBERS
                                                     EXTERIOR COLOUR                                              INTERIOR COLOUR
                                                                                          DETAILS OF SCRATCHES/DENTS/DEFECTS




                          IF VEHICLE STOLEN
IDENTIFICATION




                          PLEASE COMPLETE                                         DETAILS OF PERSONAL / HIDDEN IDENTIFICATION MARKS
                              THIS BLOCK




                                                                           DETAILS OF OTHER FEATURES WHICH WOULD ASSIST IDENTIFICATION




                        WHO IS IN POSSESSION OF SPARE VEHICLE KEYS?

                        It is recommended that any amount payable to you direct be transmitted by Electronic Bank Transfer for speedier settlement and security reasons. If
                        you are agreeable to this, please provide the following information:


                        Assignment:
                        I/We acknowledge that the party hereby authorised to effect a credit against my/our account may not cede or assign any of its rights to any third party
AUTHORITY FOR PAYMENT




                        without my/our prior written consent and that I/we may not delegate any of my/our obligations in terms of this contract/authority to any third party
                        without prior consent of the authorised party.

                        NAME OF BANK:
                        ……………………………………………………….

                        ACCOUNT NO:
                        ……………………………………………………….

                        NAME OF ACCOUNT HOLDER: ……………………………

                        BRANCH AND CODE NO: …………………………………………………



                        YOUR SIGNATURE:-………………………………………………………

                        We hereby declare that the foregoing particulars to be true in every respect
DECLARATION




                        SIGNATURE OF INSURED:

                        ………………………………………

                        DATE:……………………………….




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HIRED VEHICLE PROCEDURE – PLEASE TAKE CAREFUL NOTE

        On receiving an order the car hire agency will contact you to arrange a hired vehicle through a
         car hire company.
        They will ask where you would like to collect your hired vehicle from or where you would prefer
         to have it delivered (charges for delivery depend on the car hire company used).
        You must have a valid drivers licence.
        You will be required to pay a refundable petrol deposit. Should you bring the vehicle back with
         a full tank the deposit will be refunded.

Please take note of the following:

You are entitled to 30 days vehicle hire, however the hired vehicle must be returned no later than the
last day of the rental period ordered.
NB: Should your vehicle be repaired before the expiry of the rental period, or a payment is made to you
/ your finance house settling your motor vehicle claim, you must return the hired vehicle on the same
day. Should you not return the vehicle the subsequent days will be charged at the car hire company’s
normal rate and will be for your own account.

Should the hired vehicle be damaged whilst in your care you can be held liable for an excess as
stipulated by the car hire company.

Your insurer will only be liable for the cost of hiring a Group B vehicle and will not pay for any additional
costs charged for Personal Accident Insurance which may be offered to you through the car hire
company by another insurance company.




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