Litelok Bicycle Theft Form

Name*
Prefix First Last
Email*
Date of birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Mobile (cell) number*
Please select the level of Litelok Theft Protection you purchased*

Please describe in as much detail as possible the circumstances in which the theft took place. Please include the location of the bicycle at the time of the theft, as well as how entry/access was gained.*

Name and address of police station theft was reported to*
Police station contact number*
Crime incident number*
Did the police attend the scene?*
- Yes
- No
Was the incident reported to the policy immediately?*
- Yes
- No
If the theft was not reported to the police, what was the reason for the delay?*

Please detail how the bicycle was secured when it was stolen*
Please confirm you used the litelok which you purchased alongside your theft protection purchase to secure your bicycle*
- Yes
- No

Is the stolen bicycle also covered under a different insurance policy?*
- Yes
- No
Have you made any bicycle or cycling related claims in the past three years?*
- Yes
- No
If you answered "yes" to any of the above questions, please provide details here*

DECLARATION*
I declare that the information contained in this form is true to the best of my knowledge and I have not withheld any information connected with this claim. I accept that if I exaggerate any part of this claim, or make any false declaration or statement, I shall not be entitled to receive any benefit under this policy in respect of this claim. Furthermore, I accept that any such action on my part may render me liable to prosecution. I further agree to provide any further information or documentation as may be reasonably required. I understand that you may seek information from other insurers to check answers that I have provided. By returning this form electrically via the Yellow Jersey Cycle Insurance website in the absence of a signature constitutes acceptance of the declaration IMPORTANT NOTICE: Insurers and their agents share information with each other to prevent fraudulent claims and for underwriting purposes via the Claims Underwriting Exchange register operated by Insurance Datatype Services Ltd. A list of participants is available upon request. The information you supply on this form, together with the information you have supplied on your insurance and any other information related to the claim, will be supplied to participants.
- I have read and agree to the above declaration

Essentials