Litelok Bicycle Theft Form Step 1 of 8 - About you 0% Name* Prefix DrMissMrMrsMsProf.Rev. 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Mobile (cell) number*Please select the level of Litelok Theft Protection you purchased*SILVER - £1,000 / €1,100 / $1,250"SILVER - £1,500 / €1,650 / $1,750GOLD - £1,000 / €1,100 / $1,250GOLD - £2,000 / €2,200 / $2,500GOLD - £5,000 / €5,500 / $6,000GOLD - £10,000 / €11,000 / $12,500 Please give the make and model of your stolen bike*Approximate total value of your stolen bicycle* 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.* Who was responsible for the bicycle?*How long was the bicycle left unattended?*Time the bicycle was left by you* HH : MM AM PM Date the bicycle was left by you* Date Format: DD dash MM dash YYYY Time the theft was discovered* HH : MM AM PM Date the theft was discovered* Date Format: DD dash MM dash YYYY Were there any witnesses to the theft?*YesNoPlease provide witness details* Name and address of police station theft was reported to*Police station contact number*Crime incident number*Did the police attend the scene?*YesNoWas the incident reported to the policy immediately?*YesNoIf 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?*YesNoHave you made any bicycle or cycling related claims in the past three years?*YesNoIf 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