LIIB Pty Ltd - Motor Theft Claim Form

1INSURED

2VEHICLE

3THEFT DETAILS

4VEHICLE IDENTIFICATION

5AUTHORITY FOR PAYMENT

6DECLARATION

VEHICLE
MAKE*
YEAR*
MODEL*
REGISTRATION*
KILO'S COMPLETED
DATE OF PURCHASE
DD slash MM slash YYYY
PURCHASE PRICE
ANTI-THEFT DEVICE DETAILS
MAKE
TYPE
FITTED BY
DATE FITTED
DD slash MM slash YYYY
VEHICLE FINANCING DETAILS
FINANCE COMPANY / BRANCH
TYPE OF AGREEMENT
ACCOUNT 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
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Max. file size: 128 MB, Max. files: 2.

DATE OF THEFT*
DD slash MM slash YYYY
TIME OF THEFT*

: Hours

Minutes
PLACE OF THEFT*
WHAT WAS STOLEN?*
- VEHICLE AND ACCESSORIES
- ACCESSORIES ONLY
WAS VEHICLE LOCKED?
DETAILS OF STOLEN ACCESSORIES (PLEASE ATTACH INVOICES)
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Max. file size: 128 MB.
POLICE STATION*
SAP CASE REF NO.*
CIRCUMSTANCES OF THEFT*

AUTHORITY FOR PAYMENT
IT 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 BANK:
BRANCH AND CODE NO.:
ACCOUNT NO.:
NAME OF ACCOUNT HOLDER:
YOUR SIGNATURE*

DECLARATION
WE HEREBY DECLARE THE FOREGOING PARTICULARS TO BE TRUE IN EVERY RESPECT
SIGNATURE OF INSURED*
CAPACITY*
DATE
DD slash MM slash YYYY

INSURED