Declaration

I declare that to the best of my knowledge and belief the foregoing particulars are true, correct and a complete disclosure of the circumstances relating to the claim, and I undertake to render to the company every assistance in my power in dealing with the matter. I also declare that there is no other insurance under which a claim can be made that the said vehicle and other property is my sole property.

[* Indicates required fields]

Policy Number:
Insured's name:*
Insured's e-mail address:
Phone number - Home:
Phone number - Work:
Cellphone number:
Identity Number:
Address line 1:
Address line 2:
Address line 3:
City:
Province:
Postal code:
Occupation or business:
The Vehicle Make:
Year of manufacture:
Registration number:
1.(a) Date of loss:*
(b) Where was the vehicle left during the theft?*
Please give a description of the theft*
2. Was the Vehicle Locked?
3. SAPS Crime register number:*
Police Station and name of officer:
4. Date reported:
5. Describe any damage done to the vehicle
6. Make and model of radio / cassette player:
Value:
7. Where and when was it purchased?
8. Make and model of speakers:
Value:
9. Where and when were they purchased?
Any hire purchase?


Name of H.P. owner
In whose name is the H.P.?
I certify that the information is correct.*

I certify that I agree to the Declaration.*


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