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

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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