Property Loss Or Damage (Under R50,000) Fast Track Claim Form "*" indicates required fields 1INSURED2DESCRIPTION OF LOSS3BANKING DETAILS4DECLARATION INSURERPOLICY NUMBERADMINISTERED BROKER / AGENTYour Email Address Please enter your email if you would like a copy.INSUREDNAME*ADDRESSOCCUPATIONTEL. NUMBER*OCCURRENCEDATE OF LOSS / DAMAGE* DD dash MM dash YYYY TIME OF LOSS / DAMAGE* Hours : Minutes AM PM AM/PM LOST PROPERTYLOST PROPERTYDESCRIPTION OF PROPERTYFROM WHOM PURCHASED OR ACQUIREDDATE ACQUIREDVALUE (R) Add RemovePLEASE SUPPLY A QUOTATION FOR ITEM/S CLAIMEDUpload quotations: Drop files here or Select files Accepted file types: jpg, gif, png, 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 DD dash MM dash YYYY OTHER INSURANCEIS THERE ANY OTHER INSURANCE COVERING THIS LOSS / DAMAGE?IF SO, GIVE NAME OF INSURER. BANKING DETAILSIT 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 NUMBER 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 DD dash MM dash YYYY INSURED'S SIGNATURE*
