Property Loss / Damage Claim Form "*" indicates required fields 1INSURED2DESCRIPTION OF LOSS3DECLARATION INSURERPOLICY NUMBERBROKER / AGENTINSUREDNAME*OCCUPATIONADDRESSTEL. NUMBER* DESCRIPTION OF LOSSDATE OF LOSS:* 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? 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.POLICEPOLICE REF. NOPOLICE STATIONDATE REPORTED 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?PROPERTY LOST, STOLEN OR DAMAGEDN.B. Claims in respect of damage to buildings must be by a builder’s estimate.DESCRIPTION OF PROPERTY DATE ACQUIREDFROM WHOM PURCHASED OR ACQUIREDVALUEDEDUCTION FOR WEAR AND TEAR OR DEPRECIATION OR VALUE OF SALVAGEAMOUNT CLAIMED (R) ADD PROPERTY REMOVE PROPERTY PROPERTY LOST, STOLEN OR DAMAGEDDESCRIPTION OF PROPERTY DATE ACQUIREDFROM WHOM PURCHASED OR ACQUIREDVALUEDEDUCTION FOR WEAR AND TEAR OR DEPRECIATION OR VALUE OF SALVAGEAMOUNT CLAIMED (R) ADD PROPERTY REMOVE PROPERTY Add up to 10 repeated fields. 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
