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MOTOR CLAIM FORM

Surname Name:

First Name

Middle Name

Date of Birth		Year (e.g. 1978)

E-mail Address

Phone Number:

Home Address:


Address where loss occured:

Date of loss
DETAILS OF LOSS
Own damage:

Theft:

Fire:

Accident involving third party:

Registration of Vehicle:

Registration of other Vehicle's involved:

Vehicle involved:
DETAILS OF INSURANCE COMPANY
Name of Insurance Company:

Address of Insurance Company:

Address of Third Party Insurance Company:

Policy No :

Was the loss reported to the Police?:		Yes No

If Yes, address of the Police Station:

Period of insurance:

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