MOTOR THEFT CLAIM FORM - Colfire

OFFICIAL USE ONLY
Head Office: Corner Duke & Abercromby Street, Port of Spain, Trinidad W.I.
Telephone: (868) 623-2201-3/5 Fascimile: (868) 623-0925 E-mail: info@colfire.com Website: http://www.colfire.com
MOTOR THEFT CLAIM FORM
It is essential that all questions are fully answered whether of not a Claim is being made against the Policy. Completing all questions will expedite the processing/settlement of the claim.
1. POLICYHOLDER'S INFORMATION
Claim #
Title: First Name: Middle Initial: Surname:
Address:
City:
Telephone No(s).: Home: Work:
Mobile:
E-mail Address:
Occupation or Trade:
Policy No:
Are you V.A.T. registered?
Yes
No
If Yes, State your V.A.T. Registration Number:
Name of Employer:
Employer's Address:
City:
Is the vehicle mortgaged? Yes No If Yes, with which company
2.
PARTICULARS OF INSURED'S MOTOR VEHICLE
Registration No: Make and Model of Vehicle: Colour of Vehicle:
For what purpose was the Vehicle being used?
Are there any other Policies of Insurance in force indemnifying you in respect of this accident? Yes No
If Yes, give particulars / details
3. PARTICULARS OF DRIVER OR THE PERSON WHO LAST DROVE THE VEHICLE
Title:
First Name:
Middle Initial:
Surname:
Address:
City:
Telephone No(s).:
Home:
Work:
Mobile:
E-mail Address:
Name of Employer:
Employer's Address:
City:
Date of Birth: (YYYY-MM-DD) Age: Years Driver's Licence No:
Date First Issued: (YYYY-MM-DD) Renewal / Payment Date:
(YYYY-MM-DD)
Did the Driver hold a current Driving Licence at the time of the Theft?
Yes
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PARTICULARS OF DRIVER Continued...
Did the Driver have any previous Thefts?
Yes
No
If Yes, give please give full details:
Has the Driver ever been convicted of any offence in connection with the driving of a Motor Vehicle within the past four years?
Yes
No
If Yes, give please give full details:
Relationship of driver to Insured:
Was the Vehicle being driven with the Insured's consent and knowledge?
Yes
No
Is the Driver your paid employee?
Yes
No
If Yes, how long has he / she been employed?
Nature of his/her employment:
Does the Driver own a vehicle?
Yes
No
If YES, with which Insurance Company is the vehicle insured?
Policy No.:
4.
DETAILS OF THEFT
Date of Theft or Loss:
(YYYY-MM-DD)
Time:
(am/pm)
Location (street name etc.):
To which Police Station was the Accident / Loss Reported?
Officer's Name:
Title:
First Name:
Surname:
Officer's Badge No:
State the circumstances causing the Theft / Loss. Include a list of the missing articles, with original cost & estimated present value, and state whether anyone is
suspected of having committed the theft.
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5.
WITNESSES OF THEFT
State Names, Addresses and Ages of the occupants in the Insured Vehicle:
State Names and Addresses of any Independent Witnesses
6.
PARTICULARS OF DAMAGE TO INSURED'S MOTOR VEHICLE
Did the vehicle have an Anti theft device?
Yes
No
If Yes, State Brand
Was the device activated?
Yes
No
If no, please give particulars:
Was the vehicle locked?
Yes
No
If no, please give particulars:
Was the vehicle locked in a garage?
Yes
No
If no, please give particulars:
Has the vehicle been recovered?
Yes
No
If yes, where is the vehicle now?
Address where damaged vehicle can be seen:
Estimated Cost of Repairs:
7.
PERSONS INJURED
(Injured Person 1)
(Injured Person 2)
Name:
Name:
Address:
Address:
Telephone No(s).:
Home:
Telephone No(s).:
Home:
Work:
Mobile:
Work:
Mobile:
Date of Birth:
(YYYY-MM-DD)
Date of Birth:
(YYYY-MM-DD)
Details of Injury:
Details of Injury:
8. THIRD PARTY PROPERTY DAMAGE (1)
THIRD PARTY PROPERTY DAMAGE (2)
Owner's Name:
Owner's Name:
Address:
Address:
Driver's Name:
Driver's Name:
Address:
Address:
Telephone No(s).:
Home:
Telephone No(s).:
Home:
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THIRD PARTY PROPERTY DAMAGE (1) Continued...
Work:
Mobile:
THIRD PARTY PROPERTY DAMAGE (2) Continued...
Work:
Mobile:
Registration No.:
Registration No.:
Make & Model of Vehicle:
Make & Model of Vehicle:
Insurer:
Insurer:
Policy No.:
Policy No.:
Details of Damage:
Details of Damage:
Has any intimation of Claim been made upon you, either verbally or in writing? Yes No
Note:
Any written communication should not be answered and forwarded immediately to COLFIRE. If verbal notice has been received, particulars should
be given above.
9.
ADDITIONAL INFORMATION:
I
the undersigned do hereby authorize COLFIRE to disclose any information in respect of my Claims history to any Investigator, Adjuster, Insurance
Company, Regulatory Body or other Authority, and hereby release COLFIRE from any claims and liabilities of any kind in respect of such disclosure except
claims and liabilities that may arise under this document.
I certify that the foregoing statement is a true account to the best of my knowledge and belief.
Date:
(YYYY-MM-DD)
Insured's Signature
Date:
(YYYY-MM-DD)
Insured's Signature
Any further information which can be given should accompany these particulars.
Please use a blank sheet of paper to provide additional information where space provided is insufficient.
Be sure to attach to the Claim Form.
Download the form and fill it out on your computer.
When you are finished, save the form and submit via email to info@colfire.com
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