Motor Theft Claim Form

Policy (Or Certificate No)

Branch or Agent to whomyou paid your Last Premium

Name of Insured

Telephone No

Address (Private)

Address (Business)

Trade or Occupation (if more than one state all)

Date of Loss

Exact place

Name and address of person using vehicle immediately prior to Loss

For what purpose was he using the vehicle?

Was vehicle locked when left?

NoYes

What other precautions were taken against Theft?

Is vehicle usually kept in a locked garage?

NoYes

Explain fully how Loss occurred

When was Loss notified to Police?

Address of Police Station

Supporting Documents