Motor Theft Claim Form "*" indicates required fields 1INSURED2VEHICLE 3THEFT DETAILS4VEHICLE IDENTIFICATION5AUTHORITY FOR PAYMENT 6DECLARATION INSURER:POLICY NUMBER:ADMINISTERED BROKER/AGENT:Your Email Address Please enter your email if you would like a copy.INSUREDNAME*ADDRESSOCCUPATIONIDENTITY / COMPANY REGISTRATION NUMBERCONTACT PERSONPHONE NO.* VEHICLEMAKE*YEAR*MODEL*REGISTRATION*KILO'S COMPLETEDDATE OF PURCHASE DD dash MM dash YYYY PURCHASE PRICEANTI-THEFT DEVICE DETAILSMAKETYPEFITTED BYDATE FITTED DD dash MM dash YYYY VEHICLE FINANCING DETAILSFINANCE COMPANY / BRANCHTYPE OF AGREEMENTACCOUNT NO.AMOUNT OUTSTANDING (IF APPLICABLE)IN WHOSE NAME IS THE VEHICLE REGISTERED? (PLEASE ATTACH A COPY OF THE REGISTRATION CERTIFICATE)PLEASE ATTACH A COPY OF THE REGISTRATION CERTIFICATE Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB, Max. files: 2. DATE OF THEFT* DD dash MM dash YYYY TIME OF THEFT* Hours : Minutes AM PM AM/PM PLACE OF THEFT*WAS VEHICLE LOCKED?YesNoWHAT WAS STOLEN?* VEHICLE AND ACCESSORIES ACCESSORIES ONLY DETAILS OF STOLEN ACCESSORIES (PLEASE ATTACH INVOICES) Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB. POLICE STATION*SAP CASE REF NO.*CIRCUMSTANCES OF THEFT* VEHICLE IDENTIFICATION(IF VEHICLE STOLEN, PLEASE COMPLETE SECTION BELOW)VIN NO.ENGINE NO.EXTERIOR COLOURINTERIOR COLOURDETAILS OF SCRATCHES / DENTS / DEFECTSDETAILS OF PERSONAL / HIDDEN IDENTIFICATION MARKSDETAILS OF OTHER FEATURES WHICH WOULD ASSIST IDENTIFICATIONWHO IS IN POSSESSION OF VEHICLE KEYS? AUTHORITY FOR PAYMENTIT IS RECOMMENDED THAT ANY AMOUNT PAYABLE TO YOU DIRECT BE TRANSMITTED BY ELECTRONIC BANK TRANSFER / DEPOSIT OF CHEQUE FOR SPEEDIER SETTLEMENT AND SECURITY REASONS. IF YOU ARE AGREEABLE TO THIS, PLEASE PROVIDE THE FOLLOWING INFORMATION. NAME OF BANKBRANCH CODE NOACCOUNT NO.NAME OF ACCOUNT HOLDERYOUR SIGNATURE DECLARATIONWE HEREBY DECLARE THE FOREGOING PARTICULARS TO BE TRUE IN EVERY RESPECTSIGNATURE OF INSURED*CAPACITY*InsuredParentProxySpouseSonDaughterDATE DD slash MM slash YYYY
