A member of the Group
ONE Insurance Underwriting Managers (Pty) Ltd Reg No. 1996/008987/07Authorised Financial Services Provider FSP8783 VAT No. 4370160501
Page : 1
MOTOR THEFT/HIJACKING CLAIM FORM
POLICYHOLDER DETAILS
Insurer Mutual and Federal Risk Financing LimitedInsured Policy NumberCell Tel Number
Occupation Identity NumberE-mailWork NumberWork Address
Code
REGISTERED OWNER OF VEHICLEIf not registered in the policyholder’s name
Title, Initials & SurnameOccupation Identity NumberCell Tel NumberE-mailAddress
CodeEmployer Work NumberWork Address
Code
LAST DRIVER’S DETAILS
Title, Initials & SurnameOccupation Identity NumberCell Tel NumberE-mailAddress
Code
A member of the Group
ONE Insurance Underwriting Managers (Pty) Ltd Reg No. 1996/008987/07Authorised Financial Services Provider FSP8783 VAT No. 4370160501
Page : 2
VEHICLE INFORMATION
Date PurchasedNew or Second Hand MakeModel Year of ManufactureRegistration No. Chassis No. (VIN)Engine No. Exterior ColourInterior Colour Kilometers CompletedNon-Standard Accessories with which vehicle was equipped
Scratches, Dents, Defects and Hidden Identification Marks
ANTI-THEFT DEVICES
Make of device Fitted by Date fittedDetails of window markings Applied by whom Number
FINANCING DETAILS
Is vehicle currently subject to: Instalment-Sale Agreement Yes No
Lease Agreement Yes NoAny other type of agreement Yes No
And if soName of Finance CompanyAccount Number
A member of the Group
ONE Insurance Underwriting Managers (Pty) Ltd Reg No. 1996/008987/07Authorised Financial Services Provider FSP8783 VAT No. 4370160501
Page : 3
CIRCUMSTANCES OF LOSS
Theft Date vehicle was parked
Time parked
Place parked
Was vehicle locked? Yes No
Where did driver go after parking vehicle?Date theft was discovered
Time theft was discovered
Hijacking Date vehicle hijacked
Time hijacked
Place hijacked (exact location)
Names and telephone numbers of any passengers or witnesses.Who is in possession of vehicle’s keys (or spare keys if hijacked)?
POLICE
Name of Officer who recorded details of accident Date of reportPolice Station Police Ref no
DECLARATION
I / we declare that the aforementioned particulars are true and complete in every respect.
Signed at: _______________________________________ Date: _____________________
Full Name: ___________________________________________________________________
_____________________ __________________________Signature Capacity of Signatory*
* Please attach copy of Driver’s License