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* 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 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 INSURED'S SIGNATURE*
