LIIB Pty Ltd - Property Loss / Damage Claim Form

Property Loss / Damage Claim Form

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IT 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:
AUTHORITY FOR PAYMENT
NAME OF BANK
BRANCH CODE NUMBER
NAME OF ACCOUNT HOLDER
ACCOUNT NUMBER
YOUR SIGNATURE*

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*
DATE
MM slash DD slash YYYY

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)