Motor theft claims form

Declaration

* Please supply the vehicle keys, a copy of the Registration Certificate, and the last Service Invoice *

[* Indicates required fields]

Policy Number:*

Surname & Initials:

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:

Model:

Year:

Registration number:

Kilometres completed:

Chassis number:

Engine number:

Exterior colour:

Interior colour:

Is the vehicle being financed?

Name:

Branch:

Account number:

Type of agreement:

Outstanding amount:

Name of owner:

Identity number:

Date, time and place of theft:

Police reference Number:

Date reported:

Reported by Whom?

At which police station?

Circumstances

Was the vehicle locked?

Yes
No

If no, please give reasons:

Details of stolen accessories (Please fax proof to +264 61 402 168):

Anti-theft device details (please fax proof to +264 61 402 168)

Transcender responder device fitted:

Make:

Fitted by:

Date:

Details of scratches, dents, defects:

Details of other features which would assist identification:

I certify that the information is correct.*

(Mark box)

I certify that I agree to the Declaration.*

(Mark box)

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