Motor Theft Claim Form "*" indicates required fields 1INSURED2VEHICLE 3THEFT DETAILS4VEHICLE IDENTIFICATION5DECLARATION INSURER:POLICY NUMBER:ADMINISTERED BROKER/AGENT:INSUREDNAME*ADDRESSOCCUPATIONIDENTITY / COMPANY REGISTRATION NUMBERCONTACT PERSONPHONE NO.* VEHICLEMAKE*YEAR*MODEL*REGISTRATION*KILO'S COMPLETEDDATE OF PURCHASE DD slash MM slash YYYY PURCHASE PRICEANTI-THEFT DEVICE DETAILSMAKETYPEFITTED BYDATE FITTED DD slash MM slash 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 Max. file size: 256 MB, Max. files: 2. DATE OF THEFT* DD slash MM slash 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 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? DECLARATIONWE HEREBY DECLARE THE FOREGOING PARTICULARS TO BE TRUE IN EVERY RESPECTSIGNATURE OF INSURED*CAPACITY*InsuredParentProxySpouseSonDaughterDATE DD slash MM slash YYYY
