MOTOR THEFT CLAIM FORM - Barton Insurance Brokers

MOTOR THEFT CLAIM FORM / MOTOR DIEFSTAL EISVORM

Policy Number / Polisnommer *

Insurer *

Initials and Surname / Voorletters en van *

Company Name *

VAT Reg. No. / BTW-registrasienommer *

Occupation / Beroep *

ID Number / ID-nommer *

Telephone number / Telefoonnommer *

Email address / E-posadres *

Home address / Huisadres *

Place of loss / Plek van verlies *

Vehicle / Voertuig *

Please describe the type, make and model of the vehicle involved in the accident

Registration Number / Registrasienommer *

VIN Number / VIN (nommer *

Driver at the time of accident / Bestuurder ten tye van ongeluk *

Registered owner / Geregistreerde eienaar *

Description of loss / Beskrywing van verlies *

Please provide photos if available / Verskaf asseblief foto’s indien beskikbaar

Was the vehicle occupied / Was die motor beset? *

Was it locked? / Was die motor gesluit? *

Was tracking system activated? / Was die opsporingstelsel geaktiveer? *

SAPS Case No / SAPD-saaknommer *

Police Station / Polisiestasie *

List of property inside the vehicle at the time / Lys van eiendom binne die voertuig ten tye van verlies *

Is the property being claimed for insured anywhere else? / Lys van eiendom binne die voertuig ten tye van verlies *

Is the vehicle financed? / Is die motor gefinanseer? *

*Copy of registration documents *Copy of driver’s licence / *Afskrif van registrasie- dokument *Afskrif van bestuurder se lisensie

Click or drag files to this area to upload. You can upload up to 5 files.

Date / Datum *

Products

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