Motor Theft Claim Form "*" indicates required fields 1INSURED2VEHICLE 3FINANCE COMPANY4OWNER5THEFT6AUTHORITY FOR PAYMENT 7DECLARATION POLICY NUMBER:Your Email Address Please enter your email if you would like a copy.INSUREDCompany name / surname and initials*Company registration numberIdentity numberVAT numberOccupation or businessPhysical addressPostal addressBusiness Telephone number*Home Telephone number* VEHICLEMAKE*YEAR*MODEL*Registration number*Kilometres completedVehicle identification No.Chassis No.Engine No.Exterior colourInterior colour FINANCE COMPANYNameBranchAccount No.Type of agreementOutstanding amount OWNERNameIdentity number THEFTDate & TimeCircumstancesPlace/address where theft occurred.*Was the vehicle locked? If not, give reasons*Details of stolen accessories - are these separately insured?Details of stolen accessories - Please attach invoices Drop files here or Select files Max. file size: 256 MB, Max. files: 10. Police detailsPolice Station*Case number*Date reported DD slash MM slash YYYY Anti-theft/vehicle recovery device details MakeFitted ByDate DD slash MM slash YYYY Anti-theft/vehicle recovery device details (Please attach proof of device) Drop files here or Select files Max. file size: 256 MB, Max. files: 5. Details of window markings NumberApplied by whomDetails of scratches, dents, defectsDetails of other features which would assist identification AUTHORITY FOR PAYMENTPLEASE FORWARD THE VEHICLES KEYS (AND SPARE KEYS), A COPY OF THE REGISTRATION CERTIFICATE AND THE LAST SERVICE INVOICE.You may select for added security, payment of any amount due to you directly into a bank account. Please specify the name of the bank, branch, name of account and account number. Name of BankName of AccountBranchAccount Number DECLARATIONI/We hereby declare the foregoing particulars to be true in every respect.SIGNATURE OF INSURED*CAPACITY*InsuredParentProxySpouseSonDaughterDATE DD slash MM slash YYYY
