Motor radio claims form

Declaration

I declare that to the best of my knowledge and belief the foregoing particulars are true, correct and a complete disclosure of the circumstances relating to the claim, and I undertake to render to the company every assistance in my power in dealing with the matter. I also declare that there is no other insurance under which a claim can be made that the said vehicle and other property is my sole property.

[* Indicates required fields]

Policy Number:

Insured's name:*

Insured's e-mail address:

Phone number - Home:

Phone number - Work:

Cellphone number:

Identity Number:

Address line 1:

Address line 2:

Address line 3:

City:

Province:

Postal code:

Occupation or business:

The Vehicle Make:

Year of manufacture:

Registration number:

1.(a) Date of loss:*

(b) Where was the vehicle left during the theft?*

Please give a description of the theft*

2. Was the Vehicle Locked?

3. Police Crime/accident Register Ref No.:*

Police Station:

4. Date reported:

5. Describe any damage done to the vehicle

6. Make and model of radio / cassette player:

Value:

7. Where and when was it purchased?

8. Make and model of speakers:

Value:

9. Where and when were they purchased?

Any hire purchase?

Name of H.P. owner

In whose name is the H.P.?

I certify that the information is correct.*

(Mark box)

I certify that I agree to the Declaration.*

(Mark box)

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