AFFIDAVIT OF VEHICLE THEFT/ INCIDENT 
CLAIM #:

(This form is only required in the event that the police report omits a written statement or narrative)

Personal Information
Full Name:		Address:
City:		State:
ZIP code:		Home Phone:
Vehicle Information
Make:	Model:	Vehicle Year:	Body Type:
Color:	VIN#	License Plate#	State:
# of cylinders	Cert. Of Title#	If None, Why?
Odometer Reading	H.P. or Cubic/in.	Has vehicle been damaged?
Describe (date, type of damage, location on vehicle)
Were repairs completed?		By whom?
Name and Address of Insurance Company who paid damage claim-if any?
Purchase Information
Date vehicle purchased?	mm/dd/yyyy                     Purchased Price $		Leased  New  Used
Seller:	Dealer  Individual                   Trade-in vehicle?		Allowance $
How did you pay for vehicle	Cash  Bank Check  Personal Check   Financed		Name, address and Phone # of Finance Co.
Account #		Balance $
Date of last payment made	mm/dd/yyyy	Is account past due?	Yes  No
If so, how long has it been delinquent?	Years  Months
Theft/Incident Information
Date of Theft/Incident	mm/dd/yyyy	Time of Theft/Incident	AM  PM
Was vehicle locked?	Yes  No	Were keys left in car?	Yes  No
Are Keys in your possession?		How many sets of keys exist for this vehicle?
Location from which vehicle was taken/vandalized(BE SPECIFIC)		Reason vehicle was left at this location
When was the theft/incident reported to police/fire department?	Date mm/dd/yyyy
Time the incident was reported	AM  PM	Who reported the theft/incident?
Do you have other auto theft/comprehensive insurance   Yes  No
Name of Insurance Co.		Policy #
Please be sure all information is correct before you continue.