Name
Occupation
Home Address
Home Phone Number
Business Address
Business Phone Number
Business Fax
Email
Policy No. or Certificate No.
Renewal Date
Condition of Tyres
Name & Address of any Bank or Company with financial interest in the vehicle
Type of Road Licence, whether Private, Private CMC, Public CMC or PPV
License Plate Number
Make & Model
Year of Make
Colour
State fully the purpose for which the vehicle was being used prior to the time of the theft
If so, state the nature of the goods and the weight of the load below
If the vehicle prior to theft was driven by a person other than the Insured, by whose authority was it being used?
What is the relationship of the driver to the Policyholder?
Driver's Name
Occupation
Driver's Address
Telephone Number
Driver's License No.
Original Date Licensed Issued
At Which Tax Office
Type Of Road Licence, whether Private, Private CMC, Public CMC or PPV
Licenced to drive
Date of Birth
If yes, for how long?
If so, please give details
If so, please give details
Date of Theft
Time theft occurred
Place where theft occurred below
Address of Police Station
Name of Investigating Officer
Name
Address
Occupation
Relationship to the Insured
Nature of Injury, if any, & hospital attended
Name
Address
Occupation
Relationship to the Insured
Nature of Injury, if any, & hospital attended
Name
Address
Occupation
Relationship to the Insured
Nature of Injury, if any, & hospital attended
Give names and addresses of persons (other than passengers) who may have witnessed the theft
STATE FULLY WHAT HAPPENED PRIOR TO THE THEFT OR AT TIME REALIZING THAT VEHICLE WAS STOLEN. STATEMENT TO BE COMPLETED BY THE PERSON WHO LAST HAD THE VEHICLE IN THER POSSESSION PRIOR TO THEFT.
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