THE BROKER'S CHOICE

1

Broker

2

Insured

3

Vehicle

4

Incident

5

Documents

6

Declaration

SASTUA Motor Theft/Hijack Claim Form

Motor Theft/Hijack Claim form note: Each page should be completed in full, where applicable please advise (n/a)

Broker Details

Type of Policy * PersonalCommercial / Agri

Insured Details

Address *

Vehicle Details

Loss or Damage Occurrence

Date and Time of Loss / Damage Occurred *

When was the Loss / Damage Discovered *

Loss or Damage Place

Were premises Occupied? * YesNo

Cause of Loss or Damage

Loss / Damage occurred by Third Party? * YesNo

Previous Loss or Damage

Have you previously suffered a Loss / Damage? * YesNo

Type of Loss * Own DamageTheft / DamageThird PartyMalicious Damage

Other Interest

Does any other party have an interest in the insured property, eg. Credit agreement? * YesNo

Value

Estimated total value of all property insured under the policy *

Statement of Property lost, stolen or damaged

Please select the amount of items you want to claim for: *

Damage Report

Replacement / Repair Quotation *

Photos of Damages 1 *

Photos of Damages 2 *

Proof of ownership (in the event of theft)

Claim Form Completed By * Broker / AdminClient

Declaration

Signed Date *

Signature *