Property Loss Or Damage (Under R50,000) Fast Track Claim Form "*" indicates required fields 1INSURED2DESCRIPTION OF LOSS3DECLARATION INSURERPOLICY NUMBERADMINISTERED BROKER / AGENTADMINISTERED BROKER / AGENTINSUREDNAME*ADDRESSOCCUPATIONTEL. NUMBER*OCCURRENCEDATE OF LOSS / DAMAGE* TIME OF LOSS / DAMAGE* Hours : Minutes AM PM AM/PM LOST PROPERTYDESCRIPTION OF PROPERTYFROM WHOM PURCHASED OR ACQUIREDDATE ACQUIREDVALUE (R) ADD LOST PROPERTY REMOVE LOST PROPERTY LOST PROPERTYDESCRIPTION OF PROPERTYFROM WHOM PURCHASED OR ACQUIREDDATE ACQUIREDVALUE (R) ADD LOST PROPERTY REMOVE LOST PROPERTY Add up to 10 repeated fields.PLEASE SUPPLY A QUOTATION FOR ITEM/S CLAIMEDUpload quotations: Drop files here or Select files Accepted file types: pdf, Max. file size: 256 MB. PLACEPLACE WHERE LOSS / DAMAGE OCCURRED.TIME Hours : Minutes AM PM AM/PM DESCRIBE FULLY HOW THE LOSS OR DAMAGE OCCURRED STATING HOW (IF APPLICABLE) ENTRY WAS GAINED TO PREMISES.*HAVE YOU PREVIOUSLY SUFFERED A LOSS / DAMAGE?POLICEPOLICE REF. NO*POLICE STATION*DATE REPORTED OTHER INSURANCEIS THERE ANY OTHER INSURANCE COVERING THIS LOSS / DAMAGE?IF SO, GIVE NAME OF INSURER. I / WE SOLEMNLY DECLARE THAT I / WE HAVE SUFFERED LOSS OF OR DAMAGE TO THE PROPERTY ENUMERATED ABOVE AND THAT THE SAID PROPERTY WAS IN MY / OUR POSSESSION IMMEDIATELY PRIOR TO THE SAID LOSS / DAMAGE WHICH OCCURRED IN THE CIRCUMSTANCES DESCRIBED ABOVE. LIIB AND THE APPLICABLE SERVICE PROVIDERS CAN PROCESS THE APPLICABLE PERSONAL INFORMATION FOR PURPOSES OF ADMINSTERING THIS CLAIM.DATE INSURED'S SIGNATURE*Number
