Motor Vehicle Theft Claim Form

Kindly note the following

The purpose of this form is to register a valid motor accident claim with the insurance company.
Please ensure that the authorised signature of the policy holder/representative appears on this form– it is illegal for any other personto sign this form.
For JVC INSURANCE BROKERS to process this request quickly and correctly, please ensure that this form is completed in full.
Please complete the form in black ink OR electronically and print clearly
Where you need to make a choice between different options, please mark your selection with an X.
This form is only valid for three months from the date signed.
It is the responsibility of the insured to ensure that a claim is reported timeously. JVC INSURANCE BROKERS will not backdate any changes.
If the spaces provided are not adequate, please attach a list with all relevant details.9.Please email the completed form to the claim’s handler appointed on your claim or to your broker.

Motor Vehicle Theft Form

Policy Holder

Full Name or Company Name

ID Number

VAT Number

Contact Number

Occupation of Business

Email Address

Date of Incident

Full Physical Address

Postal Address

Full Address Where Loss Occurred

Describe Fully How the Loss Occurred

Vehicle Information

Vehicle Make and Model

Vehicle Registration Number

Kilometres Completed

Vehicle ID Number

Interior Colour

Exterior Colour

Vehicle Engine Number

Registered Owner Name

Owner ID Number

Owner Company Registration Number

Vehicle VIN Number

Vehicle Year Model

Any Window Markings?

Details of Scratches, Dents, Defects

Details Of Other Features Which Would Assist Identification

Theft Details

Date, Time And Place Of Theft

Police Station

Police Case Number

Date Reported

Reported By Whom

Circumstances

Was The Vehicle Locked? If Not, Please Provide Reasons

Details Of Stolen Accessories (Please Attach Invoices)

Please Attach Invoice 1

Upload document

Please Attach Invoice 2

Upload document

Please Attach Invoice 3

Upload document

Please Attach Invoice 4

Upload document

Please Attach Invoice 5

Upload document

Please Attach Invoice 6

Upload document

Anti-Theft Device Details

Make

Fitted By

Finance Company

Name

Branch

Account Number

Type of Agreement

Outstanding Amount

Confirmation and Uploads

Police report (if applicable)

Upload document

Proof of Tracking Device (if applicable)

Upload document

Name of Person Submitting Claim

Capacity

By accepting the above, you are indicating that you are consenting to receive future communication in this regard and that all submitted information is accurate according to your knowledge.