TEST – MOTORDIEFSTAL Eisvorm

INSURER
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Broker / Agent
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Claim number
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Policy number
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Name
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Identity number
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Occupation
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Address and (day) phone no.
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Contact person
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Make
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Model
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Year
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Registration
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Kilometres Completed
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Date of purchase
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And price paid
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Anti-theft device make
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Fitted by
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Date fitted
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Window markings number
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Applied by whom
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Finance Co./Br.
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Type of agreement
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Account no.
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Amount
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In whose name is the vehicle registered? (please attach a copy of the registration certificate)
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Date vehicle was stolen
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Time vehicle was stolen
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Place vehicle was stolen
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What was stolen?
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Details of stolen accessories
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Details of stolen accessories (place attach invoices)
Upload your documents...
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Police Station and Reference no
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Circumstances of theft
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Was vehicle locked?
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Was your vehicle stolen?
  • - select a option -
  • Yes
  • No
- select a option -
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Chassis no.
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Engine no.
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Component number
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Exterior colour
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Interior colour
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Details of scratches / dents / defects
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Details of personal / hidden identification marks
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Who is in possession of vehicle keys?
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It is recommended that any amount payable to you direct be by Electronic Bank Transfer for speedier settlement and security reasons. If you are agreeable to this, please provide the following information:

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Name of bank:
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Account no:
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Branch and code number:
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Name of account holder:
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Your signature:
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It is recommended that any amount payable to you direct be by Electronic Bank Transfer for speedier settlement and security reasons. If you are agreeable to this, please provide the following information:

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Capacity
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Select a date
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Your signature:
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Submit