Property Loss / Damage Claim Form

"*" indicates required fields

1INSURED

2DESCRIPTION OF LOSS

3DECLARATION

INSURER

POLICY NUMBER

BROKER / AGENT

INSURED

NAME*

OCCUPATION

ADDRESS

TEL. NUMBER*

DESCRIPTION OF LOSS

DATE OF LOSS:*

TIME OF LOSS:*

PLACE*

LOSS / DAMAGE PLACE

WERE PREMISES OCCUPIED? (Y/N)*

BY WHOM?

IF NOT OCCUPIED WHEN LAST OCCUPIED?

PURPOSE OF OCCUPATION

CAUSE OF LOSS / DAMAGE

DESCRIPTION OF LOSS*

IF LOSS / DAMAGE CAUSED BY ANOTHER PARTY GIVE NAME

ADDRESS OF OTHER PARTY

PREVIOUS LOSS / DAMAGE

HAVE YOU PREVIOUSLY SUFFERED A LOSS / DAMAGE?

IF SO, GIVE DETAILS.

POLICE

POLICE REF. NO

POLICE STATION

DATE REPORTED

OTHER INTEREST

ANY OTHER FINANCIAL INTEREST IN PROPERTY, E.G. CREDIT AGREEMENT?

IF SO, GIVE NAME AND INTEREST.

OTHER INSURANCE

IS THERE ANY OTHER INSURANCE COVERING THIS LOSS / DAMAGE?

IF SO, GIVE NAME OF INSURER.

VALUE

ESTIMATED TOTAL VALUE OF ALL THE PROPERTY INSURED UNDER THE POLICY. (R)

WHEN LAST VALUED?

PROPERTY LOST, STOLEN OR DAMAGED

N.B. Claims in respect of damage to buildings must be by a builder’s estimate.

PROPERTY LOST, STOLEN OR DAMAGED

DESCRIPTION OF PROPERTY

DATE ACQUIRED

FROM WHOM PURCHASED OR ACQUIRED

VALUE

DEDUCTION FOR WEAR AND TEAR OR DEPRECIATION OR VALUE OF SALVAGE

AMOUNT CLAIMED (R)

Property Loss / Damage Claim Form

INSURED

DESCRIPTION OF LOSS

LOSS / DAMAGE PLACE

CAUSE OF LOSS / DAMAGE

PREVIOUS LOSS / DAMAGE

POLICE

OTHER INTEREST

OTHER INSURANCE

VALUE

PROPERTY LOST, STOLEN OR DAMAGED

Products & Services

Company

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