Motor Theft Claim Form

Please have the following documents available in digital format if applicable

Affidavit from finance company stating no HP outstanding or latest settlement figure
Registration certificate
De-Registration certificate
Copy of last service invoice
Invoices of stolen accessories
Proof of vehicle recovery device

1. Insured

Surname & Initials:

Identity No.:

* Date:		* Approximate Time:
* Was Police on the Scene?
* Police Case No:		* Police Station:
Date Reported:		Reported By:
* Circumstances:

* Was the vehicle locked:
If NO, give reasons:

Details of Stolen Accessories:

Are these separately insured:

Anti-Theft / Vehicle Recovery Device
Make:		Fitted by:
Date:		Window Marking No.:
Applied by:

Details of scratches, dents, defects on vehicle:

Details of other features which would assist identification:

Affidavit - No HP Outstanding or Latest Settlement Figure:
De-Registration Certificate (Obtained from Assessor):
Registration Certificate:
Copy of Last Service Invoice:
Invoices of Stolen Accessories:
Proof of Vehicle Recovery Device:

I confirm all the answers to be true and complete and acknowledge the terms and conditions as set out in the policy wording and schedule *