MOTOR THEFT CLAIM FORM

The information required in this form is sought in the bona fide belief that litigation may ensue, and for the purpose of
furnishing to the solicitors of the company information to enable them to advice us on behalf of the insured in anticipation of litigation.

Please answer all questions fully and return forms without delay.

Policy No:

Claim No:

Insured:

Email:

Contact Address:

State:

Occupation:

Tel/Mobile:

Address at which vehicle usually Garaged:

Are you insured elsewhere in respect of this risk?
[select* riskElsewhere "yes" "no]

VEHICLE

Make:

Year of Manufacture:

H.P or CC:

Registration Number:

Chasis No:

Type of Body:

Colour/Combination of colours:

Where and when did you buy the vehicle?

How much did you pay for it?

How much are you claiming?

CIRCUMSTANCES

Where did the loss occur?

On what date and at what hour did the loss occur?

Was the vehicle in use with the Insured’s Permission or authority?

How was the vehicle protected before the loss?

State full circumstances under which the loss occurred?

Mileage reading at the time of loss:

Are you the sole owner of the vehicle?:

Is there any hire purchase interest? If yes, give details:

Give the date the police were advised and address of the police station?

Have you had any alteration made which are recognizable?

Are there any special fitting or accessories?

Are there any identifying features, externally, e.g. Marks, Scratches, disfigurements, etc
[select* features "Yes" "No]

IF VEHICLE RECOVERED please complete the following:

Place and date recovered:

Mileage reading at the time of recovery Details of damage sustained (if any):

Where can the vehicle be inspected?

IF THE VEHICLE HAS BEEN DAMAGED A DETAILED ESTIMATE OF REPAIRS SHOULD BE SUBMITTED AS SOON AS POSSIBLE BUT
THE REPAIRS SHOULD NOT BE EFFECTED WITHOUT THE APPROVAL OF THE COMPANY

I/WE hereby declare that the whole of the statements made by me/us in this form of Claims are in every respect true,
and I/We have made any false or untrue statement or statements, or if there be any suppression or concealment of
any material fact, my/our right to recover under the policy shall be absolutely forfeited.

Signature of Insured Witness:

Date:

Address: