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 MOTOR CLAIM FORM
The information provided is to enable the company and its solicitors to advise on and to conduct any legal proceedings, which may ensure.

CLAIM NO
Name of Insured:
Address:
Occupation:
Telephone No
Policy No:
of payment of last premium:
To Whom Did you Pay the premium:
   
PARTICULARS OF THE VEHICLE
Make
Year of Manufacture:
H.P or CC
Registered Letters and Numbers
Purpose(s) for which the vehicle was being used at the time it was stolen.
Where and when did you buy the vehicle?:
How much did you pay in N
How much are you claiming N
   

CIRCUMSTANCES
Where did the loss occur?
what date and at what hour did loss occur?
Who was in charge of the vehicle at time of loss?
Was the vehicle in use with the insured’s permission or authority?
How was the vehicle protected before the loss?
State full circumstances under which the loss occurred?
Mileage reading at the time of loss:
Are you the sole owner of the vehicle?
Is there any hire purchase interest?
Give the date the police were advised and the address of the police station
   
IF VEHICLE NOT RECOVERED
Please complete the following and forward the registration Book
(if any): Engine No
Chasis or Frame No
Type of body
Colour or Combination of colours
Have you had any alterations made which are recognisable?
Are there any special fitments or accessories?
Are there any identifying features, externally or internally, e.g. marks, scratches, disfigurements, etc.
   
IF VEHICLE RECOVERED please complete the following.
Place and date recovered:
Mileage reading at the time of recovery
Details of damage sustained (if any):
Where can the vehicle be inspected?
   

IF THE VEHICLE HAS BEEN DAMAGED A DETAILED ESTIMATE SHOULD BE SUBMITTED AS SOON AS POSSIBLE BUT THE REPAIRS SHOULD NOT BE PUT IN HAND WITHOUT THE APPROVAL OF THE COMPANY

I/We hereby declare that the whole of the statement made by me/us in this Form of Claim are in every respect true, and I/We agree that if I/We have made any false or untrue statement or statements, or if there be any suppression or concealment of any material fact, my/our right to recover under the policy shall be absolutely forfeited.
   
Signature of Insured:
Witness:
Date:
Address:
 

 

 

 

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