Property Loss / Damage Claim Form "*" indicates required fields 1INSURED2DESCRIPTION OF LOSS3AUTHORITY FOR PAYMENT 4STATEMENT OF PROPERTY LOST, STOLEN OR DAMAGED5DECLARATION INSURERPOLICY NUMBERBROKER / AGENTYour Email Address Please enter your email if you would like a copy.INSUREDNAME*OCCUPATIONADDRESSTEL. NUMBER* DESCRIPTION OF LOSSDATE OF LOSS:* DD dash MM dash YYYY TIME OF LOSS:* Hours : Minutes AM PM AM/PM PLACE*LOSS / DAMAGE PLACEWERE PREMISES OCCUPIED? (Y/N)*NoYesBY WHOM?IF NOT OCCUPIED WHEN LAST OCCUPIED? DD dash MM dash YYYY PURPOSE OF OCCUPATIONCAUSE OF LOSS / DAMAGEDESCRIPTION OF LOSS*IF LOSS / DAMAGE CAUSED BY ANOTHER PARTY GIVE NAMEADDRESS OF OTHER PARTYPREVIOUS LOSS / DAMAGEHAVE YOU PREVIOUSLY SUFFERED A LOSS / DAMAGE?YesNoIF SO, GIVE DETAILS.IF INSURED, PROVIDE NAME OF INSURERPOLICEPOLICE REF. NOPOLICE STATIONDATE REPORTED DD dash MM dash YYYY OTHER INTERESTANY OTHER FINANCIAL INTEREST IN PROPERTY, E.G. CREDIT AGREEMENT?YesNoIF SO, GIVE NAME AND INTEREST.OTHER INSURANCEIS THERE ANY OTHER INSURANCE COVERING THIS LOSS / DAMAGE?YesNoIF SO, GIVE NAME OF INSURER.VALUEESTIMATED TOTAL VALUE OF ALL THE PROPERTY INSURED UNDER THE POLICY. (R)WHEN LAST VALUED? AUTHORITY FOR PAYMENTIT IS RECOMMENDED THAT ANY AMOUNT PAYABLE TO YOU DIRECT BE TRANSMITTED BY ELECTRONIC BANK TRANSFER / DEPOSIT OF CHEQUE FOR SPEEDIER SETTLEMENT AND SECURITY REASONS. IF YOU ARE AGREEABLE TO THIS, PLEASE PROVIDE THE FOLLOWING INFORMATION: NAME OF BANKBRANCH CODE NONAME OF ACCOUNT HOLDERACCOUNT NO PROPERTY LOST, STOLEN OR DAMAGEDN.B. Claims in respect of damage to buildings must be by a builder’s estimate.PROPERTY LOST, STOLEN OR DAMAGEDDESCRIPTION OF PROPERTYDATE ACQUIREDFROM WHOM PURCHASED OR ACQUIREDVALUEDEDUCTION FOR WEAR AND TEAR OR DEPRECIATION OR VALUE OF SALVAGEAMOUNT CLAIMED Add Remove I / WE SOLEMNLY DECLARE THAT I / WE HAVE SUFFERED LOSS OF OR DAMAGE TO THE PROPERTY ENUMERATED ON THE REVERSE HEREOF AND THAT THE SAID PROPERTY WAS IN MY / OUR POSSESSION IMMEDIATELY PRIOR TO THE SAID LOSS / DAMAGE WHICH OCCURRED IN THE CIRCUMSTANCES DESCRIBED ABOVE. INSURED'S SIGNATURE*CAPACITY*InsuredParentProxySonDaughterDATE DD dash MM dash YYYY
