The Vehicle Theft Questionnaire is a written ... - GEICO
Instructions: The Vehicle Theft Questionnaire is a written statement you provide to document the details of the theft. This information is required even if your vehicle or motorcycle is recovered. To complete this form properly, include your claim number, policy number, date of theft, and fill out all sections.
GOVERNMENT EMPLOYEES INSURANCE COMPANIES
Vehicle Theft Questionnaire (Please complete even if vehicle is recovered)
Claim Number Policy Number Date of Loss
Name of Insured/Owner: _____________________________________________ Date of Birth: ______________
Residence Address: ___________________________________________________________________________
Street
City
State
Zip Code
P Telephone Number: Home: ___________________________ Business: _____________________________
O How long have you been living at the above residence? _________________years
L I
Previous Residence Address: ____________________________________________________________________
C Y
Street
City
State
Zip Code
Employer Name: ______________________________________________________________________________
H
Address: __________________________________________________________________________________________________
O
Street
City
State
Zip Code
L Occupation/Position: ________________________________________________ Length of Service: ___________
D E
Social Security #: ________________ Driver's License #: ___________________________________ State:_____
R Marital Status: Single
Married
Divorced
Separated
Widow
Spouse's Name: ____________________________________________ Date of Birth: ____________________
A
N Address: (If different from residence address) __________________________________________________________
D
Street
City
State
Zip Code
Telephone Number: Home: ___________________________ Business: ___________________________
O Employer: ________________________________________________________________________________
W Address: _________________________________________________________________________________
N
Street
City
State
Zip Code
E
Occupation: _______________________________________________________________________________
R
Social Security #: _________________ Driver's License #: ______________________________ State:_____
I
Others Residing In Household:
N
NAME/RELATION
SEX
F
Male
Female
O R M A
Male Male Male
Female Female Female
DATE OF BIRTH
T
Other Vehicles Located At Residence Address:
I
YEAR
MAKE
MODEL
O
PLATE NO.
N
DRIVER'S LICENSE NUMBER INSURANCE COMPANY
Vehicle Identification Number (VIN):
___________________________________
State: ______________ License Plate Number: ______________________________ Mileage _______________ Year: _____ Make: ______________ Model: ___________________ Color: __________ Special Packages: __________
V Please check any vehicle options that apply:
E Transmission
H
I
Overdrive
Power Power Steering
C
4 Wheel Drive
Power Brakes
L
Positraction
E
Power Windows Power Locks
I Transmission Type
N
F
Automatic Transmission
O
6 Speed Transmission
Power Driver Seat Power Passenger Seat Power Antenna
5 Speed Transmission 4 Speed Transmission 3 Speed Transmission
Power Mirrors
Power Trunk/Gate Release
Power Adjustable Pedals
Radio AM/FM Stereo Radio CD Player CD Changer/Stacker Premium Radio Satellite Radio Steering Wheel Touch Controls Auxiliary Audio Connection Equalizer
Seating Cloth Seats Leather Seats Reclining/Lounge Seats Bucket Seats Heated Seats Rear Heated Seats 3rd Row Seat Power Third Seat
C-116 TX (03-14) NS
1
Decor/Convenience
Roof
Safety/Brakes
Wheels
Air Conditioning
Electric Glass Roof
Driver's Side Air Bag
Auto Level
Aluminum/Alloy Wheels
Climate Control Rear Defogger Tilt Wheel Telescopic Wheel
Electric Steel Roof Skyview Roof Dual Power Sunroof Manual Steel Roof
Passenger Air Bag
Front Side Impact Air Bags
Rear Side Impact Air Bags
Head/Curtain Air Bags
Exterior/Paint/glass Luggage/Roof Rack Exterior Woodgrain Rear Window Wiper
Chrome Wheels 20" Or Larger Wheels Deluxe Wheel Covers Full Wheel Covers
Cruise Control
Manual Glass Roof
Alarm
Two Tone Paint
Spoke Aluminum Wheels
Keyless Entry
Flip Roof
Night Vision
Three Stage Paint
Styled Steel Wheels
Console/Storage
T-top/Panel
Intelligent Cruise
Clearcoat Paint
Wire Wheels
Overhead Console Entertainment Center Navigation System Communications System
Heads Up Display
Glass T-tops/Panel Power Convertible Top Detachable Roof
Vinyl Covered Roof
Cabriolet Roof
Parking Sensors Parking Sensors W/Equip Anti-lock Brakes (4)
Anti-lock Brakes (2)
4-wheel Disc Brakes
Metallic Paint Rear Spoiler Fog Lamps Tinted Glass Privacy Glass
Wire Wheel Covers Rally Wheels Locking Wheels Locking Wheel Covers Additional Items not listed:
Wood Interior Trim
Electronic Instrumentation
On Board Computer
Landau Roof Padded Landau Roof Padded Vinyl Roof
Roll Bar Traction Control Stability Control
Body Side Moldings Dual Mirrors Heated Mirrors
Message Center Memory Package Remote Starter
Headlamp Washers
Signal Integrated Mirrors
Please list any customizations or modifications to the vehicle. This should include any non-factory installed items:
C Customization (Please include brand name and model information) U S T O M
Date Installed
Value
Purchase/Lease Date: _______________
NEW
USED
Purchase Price: $____________
Seller's Name: __________________________________ Telephone Number: ________________________
Address: ________________________________________________________________________________
S A
Trade In?
NO
YES Value of Trade In: $_________________________
L Lienholder/Leasing Co. Name: ___________________________________________________________________
E
Address: ________________________________________________________________________________
S
Street
City
State
Zip Code
Telephone Number: ___________________________
D
A
Account Number: _______________________________ Down Payment: __________________________
T
Last Payment: $_________________________________ Date: __________________________________
A
Has vehicle ever been repossessed?
NO
YES
Is the vehicle currently under a repossession order? NO
YES
Are payments up to date?
YES NO Lienholder notified of THEFT?
YES
NO
Do you have any other outstanding loans on this vehicle or its equipment? NO YES
If yes, with whom? __________________________ Amount? $_______
Owner(s) as shown on title: _________________________________________________________________
Name of Service Station: ____________________________ Telephone Number: ________________________
S Address of Service Station: _____________________________________________________________________
E
Street
City
State
Zip Code
R
V Date of Last Service: _____________________ Work Performed: __________________________________
I List any work performed since purchase other than tune-up, oil, grease:___________________________________
C E
____________________________________________________________________________________________
When & Where Repaired: ______________________________________________________________________
C-116 TX (03-14) NS
2
Has vehicle been involved in any losses since its purchase?
NO
YES
P Date of Loss: _____________________ Location: ________________________________________________
R Type of Loss: ________________________________________________________________________________
I O
Damages/Area: _______________________________________________________________________________
R Amount: $____________________________________ Repairs Completed?
NO
YES
Insurance Company: ___________________________________________________________________________
D
A Repair Shop Name: _______________________________ Telephone Number: _______________________
M
Address: ________________________________________________________________________________
A
Street
City
State
Zip Code
G Was there any unrepaired body or mechanical damage on the vehicle prior to the theft? NO YES
E
If "YES" list damages: ____________________________________________________________________________
Who had custody of vehicle at the time of the theft? __________________________________________________
Exact location of theft: __________________________________________________________________________
Reason car at location: _________________________________________________________________________
T Date and time vehicle last seen before theft: _____________________
____________ A.M.
P.M.
H E
Date and time vehicle discovered missing:
_____________________
____________ A.M.
F How many keys were you provided at the time you purchased the vehicle? ______________
P.M.
T Did you have any additional keys made for this vehicle? NO
YES If yes, how many?_______
I Are there any keys missing?
NO YES When did you notice these keys missing?____________________
N Were there any keys in or upon the vehicle at the time of the theft? NO YES Where?_________________
F O
Does the vehicle have either a factory or aftermarket remote starter?
NO
YES
Was the vehicle locked? NO YES Alarm in use?
NO YES N/A
Was vehicle parked in a tow away zone?
NO
YES If Yes, did police tow it?
NO
YES
Are there any outstanding parking tickets?
NO
YES
Briefly describe any vehicle usage 24 hours prior to theft, up to and including a description of the loss:
L O S S
I N F O
Who notified police? ____________________________________________________________________________
Precinct: ________________________________
Agency/Department: _______________________________
G Case Number: _________________ Officer: __________________________ Badge Number: _____________
E
N Date and time theft reported: _____________________ Time: _________ A.M. P.M. By Phone In Person
E
R ARE YOU RENTING A CAR DUE TO THE THEFT?
NO
YES If "YES", please provide:
A L
Rental Co.: ____________________________________
Telephone Number: __________________________
WAS THE STOLEN VEHICLE LOANED OR BORROWED?
NO
YES
I If "YES", complete this section:
N F
Name: ____________________________________________
Telephone Number: ______________________
O Address: ____________________________________________________________________________________
R
Street
City
State
Zip Code
M A
Relationship: __________________
Purpose: ______________________
Does borrower own a vehicle?
YES
NO
T WAS VEHICLE PARKED IN PUBLIC GARAGE OR PARKING LOT? NO YES If "YES", complete this section.
I O
Name of parking lot/garage: _________________________________________________________________________
N Address: ________________________________________________________________________________________
Insurance Company of garage:_______________________________________________________________________
Who parked the car? __________________________________ Who was given possession of keys ? Attendant: __________________________________________________________
C-116 TX (03-14) NS
3
P
O Have you or any member of your family ever had a vehicle stolen?
NO
YES
L
I If yes, Date: _____________________ Location: _________________ Insurance Company: __________________
C E
If recovered, its condition: _______________________________________________________________________
Do you have any other Theft Insurance on stolen vehicle?
NO
YES ____________________________
I N
Is the vehicle that is reported stolen legally registered and titled at the Department of Motor Vehicles that issued the
F title and plates?
NO
YES
O Name and contact information of suspected thief:___________________________________________________
R RECOVERY
E C
Date: ______________ Time:
A.M.
P.M. Place:____________________________________
O Recovery Reported to GEICO?
NO
YES Date: _____________________
V
E Is vehicle drivable?
YES
NO Who recovered the vehicle? ____________________________________
R Y
Arrests made?
NO
YES Name and Address: ____________________________________________
Damage due to theft?
NO
YES Describe: _______________________________________________
D A
Was vehicle viewed by policyholder?
NO
YES Where: _____________________________________________
T Vehicle located at the present time:________________________________________________________________
A
Telephone Number: _______________________________
P IF THERE WERE ANY PERSONAL ITEMS IN YOUR VEHICLE THAT REMAIN UNRECOVERED AND YOUR
E POLICY PROVIDES COVERAGE FOR PERSONAL EFFECTS, PLEASE COMPLETE THIS SECTION:
R S
Please list items separately in the spaces provided below:
Value of each item:
O
N
A
L
E
F
F
E
C
TOTAL VALUE OF UNRECOVERED ITEMS (LIMIT OF $200):
T NOTE: LOSS TO ANY TAPE, WIRE, RECORD DISC OR OTHER MEDIUM FOR USE WITH A DEVICE DESIGNED FOR THE RECORDING
S AND/OR REPRODUCTION OF SOUND IS NOT COVERED. OTHER EXCLUSIONS MAY APPLY. PLEASE REFER TO YOUR CONTRACT.
If the identity of the person or persons responsible for the theft of this vehicle is established, are you willing to
prosecute that person or persons?
YES
NO
Texas law requires the following to appear on this form. "Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison."
I swear that the information contained in the prior four (4) pages are true and correct to the best of my knowledge.
Name: _______________________________________
Address: _____________________________________
Signature: ____________________________________
Date: ________________________________________
C-116 TX (03-14) NS
4
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