Stolen or Burnt Out Motor Vehicle Claim Form


IMPORTANT - Please read before completing this form.

Many of the fraudulent claims we receive are made as Stolen or Burnt Out Motor Vehicle claims.

This usually has the result of increasing premiums and raising excesses. Rather than penalising you our honest and loyal clients whose support we value we’d prefer to ask your help in filling out this form.

Particularly we would point out that where items within a claim are proven to be inflated, the total claim will be declined.

We will be carefully monitoring all claim information with the aim of paying genuine claims quickly, stopping expensive fraudulent claims and keeping your premiums down.

Thank you for your co-operation.
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1    Personal Details
Customer Reference
Title
Insured's Full Name(s) 
Date(s) of Birth    
Email Address 
Telephone Number 
Day
Night
Postal Address 
Postcode 
 
Interested Party
(Bank, Finance Company etc)
Postal Address
Postcode
 
 
2    What Happened
Date of loss
Between the hours (approx) of  and 
Date loss was discovered
Time
Who discovered the loss?
Was the vehicle alarmed?
Was Alarm set
Is vehicle normally garaged
Details of how loss occurred
Where were you at the time of the theft or loss?
Place where loss occurred
 
 
3    Police Details - Please read this carefully
Did the Police attend the scene? Yes No
If NO, have the Police been notified of the loss? Yes No
If YES, which Police Station was the loss reported to?
On which date?
Have the Police recovered any property? Yes No
If YES, please give details
Has the loss been advertised in any newspapers? Yes No
If YES Paper   Date
Other action taken to recover property
 
 
4    General - Please answer all questions
Owner's Full Name
Address
Phone Nos
Day
Night
Usual Driver's Full Name
Address
Phone Nos
Day
Night
Year
Make, Model and Type (state - 2 Door, 4 Door, Hatch, Station-wagon)
Registration No.
HP or CC Rating
Odometer Reading (KMs)
Transmission (state - Manual 3/4/5 speed, overdrive), Automatic, Turbo
V.I.N. No.
Engine No.
Modifications
Air Cond. Yes No
CNG/LPG Yes No
Any other modifications? (please detail)
Colour (detailed)
Colour changes made by present owner
Tyres
Make
Type
Amount of wear in tyres and tread pattern:
Front left
Front right
Rear left
Rear right
Spare
Wheels
Colour
Mags
Standard
Radio/Stereo
Unit Make
Model
Where fitted in Vehicle
Speakers
Where fitted
Make
Type
Interior trim colour
Interior trim condition Poor Average Good Excellent
Other Vehicle Accessories
The Vehicle is usually serviced by
Phone
The Vehicle was last serviced by
Phone
Date Vehicle was last serviced
Warrant of fitness expires on
Registration expires on
Condition of the following was (ie good, poor, etc):
Engine
Mags
Transmission/Diff
Suspension
Steering
Body
Paintwork (faded/patchy)?
Seats
Dash
Was there any unrepaired damage (including rust) on the vehicle? Yes No
If YES, please detail
The following people have keys to the vehicle - names, addresses and phone numbers
Number of owners
Is there any finance on vehicle? Yes No
If YES, with whom?
Purchase price of vehicle
Purchase date of vehicle
Purchased from whom? (ie Dealer)
Was the vehicle for sale or trade prior to the loss? Yes No
If YES, how was it advertised and what was the asking price?
Have you had any repairs done to the vehicle? Yes No
If YES, please provide repair details and advise repairer's name
In the last five years have you
Had any insurance cancelled or refused? Yes No
Been charged with or convicted of any criminal offence (other than parking)? Yes No
If YES, give full details
 
 
5    Declaration
Where any declaration is answered NO then further details will need to be provided below in the box headed 'Exceptions to this Declaration'.
I/We declare that:
All the statements in this claim form and any additional schedules are correct.  Yes No
The motor vehicle and/or accessories are correctly described in this form and were lost, stolen or damaged under the circumstances described overleaf.  Yes No
I/We have told TOWER Insurance everything relevant to this claim.  Yes No
I/We understand that:
Wilful or reckless exaggeration or inflation of the amount claimed will forfeit the claim and may result in prosecution.
The personal information provided in this claim form is being collected by TOWER Insurance to enable it to evaluate my/our claim.
I/We have certain rights of access to and correction of the personal information provided by me/us on this claim form or in support of this claim, but if I/we do provide incorrect information, TOWER Insurance may be entitled to decline the claim whether or not it is later corrected.
If any of the property in this claim for which I/we have received payment is subsequently recovered I/we will notify TOWER Insurance immediately and return the property to TOWER Insurance or will refund to TOWER Insurance the value of the recovered items.
I/We authorise TOWER Insurance to obtain personal information about me/us from any other party.
I/We authorise TOWER Insurance to obtain if required a copy of the police report from the Police relating to this claim.
Exceptions to this Declaration: