Mr. Tony Savage has submitted a claim for a damaged tire on his 2012 Jaguar XF Sportbrake. While driving home on February 17, 2014 at 11:30 PM, he encountered debris from an accident and believes this is what caused the puncture to his tire. The damaged tire is a Dunlop brand and was replaced by Grange Motors in Brentwood, Essex. Mr. Savage is required to keep the damaged tire for 28 days for inspection purposes.

1. Grange Motors(Brentwood)
Ltd
2, Brook Street. BRENTWOOD, Essex, UK , CM14 5LU.
Tel: 01277216161
e-mail: chris.hill@grange.co.uk
Grange Motors (Brentwood) Ltd
Website:
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JAGUAR
Invoice Number: 415J/710791
Date: 24/02/2014
Invoice to
Mr Tony Savage
39, Harrow Drive
HORNCHURCH
RMI11NS
UK
Account Number: SCASH
Repair Order Number: 41SJ/45008/R
JAGUAR XF DIESEL SPORTBRAKE 3.0d V6 S Portfolio 5dr Auto (2012 - )
Reg No: H20TC5 Chassis No: SAJAC0323DNS72917
Mileage: 3,036
Driver:
Page
Retail
1 of 1
Authorisation/ Order Number: Signed Repair Order
Totals
~~-~.~.
No.
1
labour
Op. Code
VAT Code
Description
Parts
Parts No.
255/35ZR20DLOPSPMAXXJ97Y
Value
0.00
Retail
Description
255/3520DMAX97Y
_.
Stand
Renew OSR tyre
1
Seiling
VAT Code
Value
258.70
258.70
Stand
258.70
Task Total:
Totals by Authorisation
~"
~~
-.ii._
258.70
~;
_~_
.
Totals
Authorisation
258.70
Signed Repair Order
Total Value:
258.70
Totals by VAT
Value
Stand
VAT Rate
Totals
258.70
VAT Code
20.00
51.74
Total VAT:
51.74
Grand Total: £310.44
Balance Outstanding:
310.44
Invoice Messages
Your service advisor was: Mick Burgess
The technician(s)
who completed this work were: Dean Taunton
Your next service will be due on: 31/01/2015
Your next MOT test will be due on: 25/01/2016
Check the engine oil level every fourth fuel tank fill or weekly - which ever is the sooner.
It is important to check the engine oil level regularly.
Running the engine with engine oil below the lower mark or above the upper mark can cause serious engine damage.
Thank you for your custom.
Receive 10% off your next service when you book online at www.grange.co.uk
other offer.
Use promotion code RR2012, not to be used in conjunction with any
For exclusive offers and VIP events visit www.Grangecarclub.co.uk
We have carried out a free vehicle health check.
You may receive a questionnaire from Jaguar Cars relating to this service visit. It is our aim to offer you OUTSTANDING levels of customer service; we
hope this has been achieved. Thank you for your custom and loyalty to Grange Jaguar
The road wheels of your vehicles have been removed and the 2 mating surfaces have been cleaned and lubricated. This Is to aid wheel removal should
you ever have a puncture. This is not part of this service schedule and has been carried out free of charge for your peace of mind.
Grange Motors (Brentwood) Ltd Registered Office: Dorean Way, Swindon, SN3 3RA
Registered in England No. 616119
VAT Registration No. GB 218 1290 83

2. Tyre ClaIm form 2013 07 V9 AI Docs Upload
To be completed by the Tyre fitter I Repairer
Eor multiple tvre claims please enter tread depths for each tvre
Part B
TYRE VALIDATION
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Customer Name:
Vehicle Registration number:
Vehicle Mileage?
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27°Cr
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What caused the damage to the tyre(s)?
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Was the tyre(s) driven on whilst damaged?
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Which tyre(s) is damaged?
Is the tyre(s) repairable? If not, what is the
reason for this?
No
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What was the remaining tread depth on the
damaged tyre(s)? At the lowest point across
the tyre (in millimetres)
Inner
Middle
mm
ttl /IJ CIJ(f' SPI'vl~K
Tfttt ,p_
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Date of repair/replacement.
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Tyre Repair Centre Address/company
Tyre Repair Centre Telephone number.
peclaratlon to be completed
by
Outer
mm
mm
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Brook Street
Brentwood
Essex CM145LU
.,.lO1217l216161
Facsimilie (012n) 220187
www.grange.co.uk
stamp.
Name of person who repaired/replaced
tyre.
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Make & Serial Number of Damaged Tyre(s)
ON
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I certify that the above statements in Part B are true and correct and I understand that if I have knowingly made
a false representation any payment under the customer's tyre Policy may be withheld and the customer's
Policy may become Invalidated. We agree to keep the tyre/s for 28 days clearly labelled, should Itlthey be
required for Inspection purposes.
Fitter's Name
Fitter's Signature
J123n41 - MrT Savage
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Date
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Our Ref:
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3. Tyre ClaIm form 2013 07 V9 AI Docs Upload
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 payments may be invalidated and the Policy may be made void.
I consent to the seeking of information from, and giving of information to other Insurers to check the answers I have
provided.
I understand that it is my responsibility to ensure the tyre(s) are kept available for 28 days, should they be required for
inspection purposes.
Data Protection
By signing this declaration, I agree for the insurer and/or Premia Solutions limited to process my claim using the
information I have provided. I agree for the insurer and/or Premia Solutions limited to respond to enquiries from the
Police concerning your policy or claim in the normal course of investigations.
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
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S,AVA~'
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Insured's Signature
Date:
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11231741 - MrT Savage
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Our Ref:
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4. Tyre ClaIm form 2013 07 V9 AI Docs Upload
For office use:
CLAIMFORM
Tyre Claim Form
Please complete all the details on this form. Please then ensure that you sign and date where indicated
and upload the form to: http'Uuploads pslsynergy,coro
«
IMPORTANT»
You must enclose ALL the documents specified under the Required Documents
section at the end of this claim form or we will be unable to process your claim
PartA
(to be completed
Your Personal and Vehicle Details
by you)
Name:
T.C.SAVAGE
39 HARROW DRIVE
HORNCHURCH
Address:
ESSEX
RM111NS
01708472328
Best contact telephone number:
Gofal@aol.com
Email address:
RETIRED
Your occupation:
~AGUAR XF SPORTBRAKE
Vehicle make and model:
H20TCS
Vehicle registration number:
~700
Vehicle mileage:
What is the vehicle used for?
PRIVATE SOCIAL
Please confirm if you are VAT Registered, if the claim
is for a company vehicle or you are self employed
Date and time of incident giving rise to
claim:
17/02/2014
- 11.30 PM
~
J123f7 41 - Mr T Savage
_
Our Ref:.

5. Tyre ClaIm form 2013 07 V9 AI Docs Upload
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Which tyre(s) are damaged?
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hilst driving home I approached an accident scene. There was a great deal
debris over which I had to pass. I assume it was there that I acquired the
uncture.
r:
Provide a detailed description of the
incident giving rise to the claim.
Dunlop
Make of Tyre
Example: Pirelli, Continental
Was the incident caused by a road traffic
accident?
YES
~anuary 20144
When was the vehicle last serviced?
Crime reference number:
(if applicable)
~
)1231741 - MrT Savage
~
Our Ref:,