Swan

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MOTOR VEHICLE

• Make:
• Model:
• Year:
• Registration No:
• Engine No:
• Chassis No:
• Colour:
• Speedometer
  Reading:
• Any special distinguishing features or marks:
• Attach copy of white book.

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  Maximum file size: 2MB

GENERAL INFORMATION

• Date of Loss:
• Time:
• Place of occurence:
• If the vehicle was in use, state:
• (a) Name and address of driver:
• (b) Age of driver:
• (c) Number, date and place of issue of driving licence:
• (d) Is the driver your employee?

  Yes No
• (e) If so, in what capacity?
• (f) Purpose for which vehicle was being used:
• (g) Nature of goods carried, if any:
• (h) If vehicle is subject of an hire purchased Agreement name Corporation:
• (i) Is the property lost or damaged insured with any other Corporation?
• Please give a full account of circumstances surrounding the accident or loss:
• Attach copy of driver’s license.

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IN THE EVENT OF FIRE PLEASE STATE

• Probable cause of fire:
• Nature of damage caused:
• Name and address of any witness:
• If fire occurred in a garage or building, please give name and address of proprietor:
• Date of Loss:
• Time:
• Attach copy of fire brigade report

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IN THE EVENT OF THEFT PLEASE STATE

• Have the Police been notified?

  Yes No
• By whom?:
• If so, state name of policeman and station:
• Was the vehicle left securely locked?:

  Yes No
• Are the keys still in your possession?:

  Yes No
• Do you suspect any particular person(s)?:

  Yes No
• If so give details:
• Has vehicle been recovered?:

  Yes No
• By whom?:
• What damage has it sustained?:
• Where may vehicle be inspected?:
• Have any instructions for repairs been given:

  Yes No
• Name of proposed repairs:
• Estimated Repair Cost K:
• Attach copy of police report.

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VEHICLE ACCESSORIES DAMAGED OR STOLEN

NOTE: ITEMS STOLEN THAT ARE NOT VEHICLE ACCESSORIES SHOULD BE CLAIMED ON “ALL RISKS” POLICY IF YOU HAVE ONE

• Description of accessories: please state make, model and serial number

• • Where purchased

  • Date of purchased

  • Cost price

  • Deduction for age wear and tear

  • Amount Claimed

• Accessories
• • Where purchased
  • Date of purchased
  • Date of purchased
  • Deduction for age wear and tear
  • Amount Claimed

• Accessories
• • Where purchased
  • Date of purchased
  • Cost price
  • Deduction for age wear and tear
  • Amount Claimed

• Accessories
• • Where purchased
  • Date of purchased
  • Cost price
  • Deduction for age wear and tear
  • Amount Claimed

• Accessories
• • Where purchased
  • Date of purchased
  • Cost price
  • Deduction for age wear and tear
  • Amount Claimed

• Accessories
• • Where purchased
  • Date of purchased
  • Cost price
  • Deduction for age wear and tear
  • Amount Claimed

• TOTALS

• Attach copy of quotation.

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  Maximum file size: 2MB