Mercedes-Benz Tyre and Alloy InsuranceClaim Form

Please complete all the details on this form. Please then ensure that you sign and date where indicated and return the form to:

AutoProtect LimitedOR Email the completed form to:

Warwick HousePlease include your vehicle registration and policy number in

Roydon Road the subject line

Harlow

Essex

CM19 5DY

Please ensure YouencloseALL the documents specified under the “Required Documents”

section at the end of this claim form or we will be unable to process your claim.

Name:
Email Address:
Best contacttelephone number:
Vehicle registration number:
Vehicle mileage:
Date and time of incident giving rise to claim:
Please indicate which wheel and/or tyre is damaged
(Please tick appropriate wheel) /
Please give a detailed description of how the incident occurred
Are the wheels and/or tyres the ones that were originally supplied with the vehicle? / YES NO
If NO please provide full details:

Insured’s Declaration

I certify that the above statements are true and correct and I understand that if I have knowingly made a false representation any claim may be invalidated and the policy may be made void.I understand that once you have assessed the claim based on the information provided I may be asked to take my car to the supplying dealer in order that the claim may be investigated further.

I consent to the seeking of information from, and giving of information to other insurers to check the answers I have provided.

Data Protection

Where necessary to administer your policy efficiently or protect your interest, we may disclose the data that you have supplied to other third parties, such as loss adjusters, solicitors, other insurers. It is important that the data you supply to us up to date. Upon request from you we will let you know what information we hold and provide a copy in accordance with the Data Protection Act (a charge will be made).

Insured’s Name______

Insured’s Signature ______

Date______

Documents Required with ALL claims:

  1. Fully completed Claim Form with good quality photographs of the damaged wheel and/or tyre.

IMPORTANT

  1. Please ensure that the wheel is thoroughly cleaned before the photographs are taken
  2. Please photograph the damaged wheel and/or tyre from straight on

Please print and attach the photographs to your claim form or alternatively email your digital photograph(s) and completed claim form to