MOTOR THEFT CLAIM FORM
   
INSURED

 
Name:    
Address: Occupation:
Cell: Telephone No:
Fax No: Email Address:
Id No: Vat No:
   
FINANCE COMPANY
Name:
Branch:
Account number:
Type of agreement:
   
VEHICLE
Make
Model:
Year:
Registration number :
Km travelled :
Date of last service :
VIN number:
Chassis number:
Engine number:
Exterior colour:
Interior colour:
Registered owner:
 
THEFT
Name of driver prior
to theft:
Age:
Relationship to
insured - If applicable:
Date & time of theft:
Place of theft:
Police station:
Police reference:
Date reported:
Reported by:
Circumstances:
Was alarm activated, if not give reasons:
Was the vehicle locked? If not give reasons:
   
ANTI-THEFT VEHICLE RECOVERY DEVICE DETAILS
Make:
Fitted by:
Date:
Details of dents, scratches defects
Stickers/Sign Writing?
   
PAYMENT METHOD
Name of bank:
Branch:
Account Holder:
Branch Code:
Type of account:
Account number:
   
DECLARATION
I/We solemnly declare that the above particulars are true in every respect.
   
Signature: