Stolen Vehicle Form

Claimant's Declaration*
I declare that to the best of my knowledge and belief, the information to be provided by me is true and correct, and that I will not withhold any information connected with this claim being filed by me.
I understand that Gulf Insurance Limited requires the information in this form as part of its review of the claim being filed by me.
I am aware that failure by me to provide information that is true and correct, or which I believe may not be true and correct, or withholding information relevant to this claim may result in Gulf Insurance Limited denying or voiding my claim, and/or pursuing criminal actions and/or civil proceedings against me in accordance with the relevant laws of the land.

THE ACCIDENT OR OCCURRENCE
Description*
Date of Accident*
Date Format: DD slash MM slash YYYY
Hour*
Please enter a number from 1 to 12.
Minutes*
Please enter a number from 0 to 59.
AM/PM*
Please state exactly what the vehicle was being used for at the time of the accident*
Other*

LOCATION OF OCCURRENCE
Address 1
Town/City*
Address 2
Country*
Was the accident reported to any police station?*
- Yes
- No
Please State badge number of Police Officer.*
(If unknown, please state unknown)
Please state name of Police Station*
Please state name of Police Officer*
(If unknown, please state unknown)
First Last

Signature*
- Type-in Signature
- Digital Signature
Show Digital Signature
Signature*
Signature*
Declaration
By signing or printing my name, I agree that this signature will be an electronic representation of my signature for all purposes when I use them on this document, just the same as a wet ink signature on paper.
Date*
Date Format: DD slash MM slash YYYY
Would you like this form to be e-mailed to an additional person?*
- Yes
- No
Email*

Stolen Vehicle Claim Form