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MOTOR THEFT/FIRE CLAIM FORM

PLEASE NOTE: An agent who completes a Proposal Form does so as an agent of the proposer.

It is essential that every question with * be answered fully for proper processing of the form.

POLICY NO.

(a)

Full Name of Insured *

(b)

Full Postal Address *
(to which all correspondence would be sent)

(c)

Occupation
(Pls give full details)

(d)

Mobile Tel. No. *

(e)

Tel. No.

(f)

Fax No.

(g)

E-mail Address *

(h)

Inception Date

(i)

Branch

VEHICLE INSURED PARTICULARS

		Vehicle
a.	Make of each vehicle *
b.	Registration no. *
c.	CC
d.	Year of manufacture
e.	Engine Number
f.	Chasis Number
g.	Mileage Covered
h.	Purpose being used
If commercial, type of use
i.	Own Goods
j.	Goods only
k.	General Cartage
l.	Taxi/Bus
m.	If Taxi/Bus How many passengers were carried at the time of loss?

PERSON IN CHARGE OF THE VEHICLE AT THE TIME OF THEFT/FIRE ACCIDENT

Name			Age
Address
Was the Vehicle used with your permission?
For what purpose was it used at the time of loss?
Are there any other insurance cover on the vehicle?
If so, give policy Nos & Names of Insurers
Relation of Driver to Insured			If Paid Driver, for how long employed
Does Driver own a vehicle?
If so, Name and Address of Insurer

PARTICULARS OF THEFT/FIRE INCIDENT

Who discovered the loss?
Date of incident			Time
Exact Location of Accident
Cause of Fire			Speed of vehicle
Did Fire Brigade attend?			If so, which station
Did Police attend?			If so, which station

FULL STATEMENT OF THEFT/FIRE INCIDENT

Who do you suspect for the loss?
When did you last service the vehicle?
By whom, at where?

WITNESS			OCCUPANTS OF YOUR VEHICLE
Name			Name
Address			Address
Name (2)			Name (2)
Address (2)			Address (2)

DAMAGE TO INSURED VEHICLE

Full details of Damaged Parts
Present Location of Vehicle
Rough Estimate of Repairs
Repairer's Name and Address
Inventory of Damaged Parts

THIRD PARTIES INVOLVED IN THE ACCIDENT

Name
Address
Type of property/Injury
If Vehicle, Make
Registration No
Year of Make
Present location of Vehicle
Is Owner Insured
If Yes; Policy No.
Name and Address of Insurer

If notice of third party claim has been given verbally or in writing, give full particulars:

If any written communication is recieved, please forward it immediately unanswered:

DECLARATION - I/We declare the foregoing particulars to be true and I/We authorize LEADWAY ASSURANCE COMPANY LIMITED and/or their Legal representatives to deal with all matters arising from this accident at their discretion and if they deem it expedient to admit liability and/or negligence on the part of myself/our servants or Agents

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