Property Loss Or Damage (Under R50,000) Fast Track Claim Form

i capital Group Companies:

"*" indicates required fields

1INSURED

2DESCRIPTION OF LOSS

3DECLARATION

INSURER

POLICY NUMBER

ADMINISTERED BROKER / AGENT

NAME*

ADDRESS

OCCUPATION

TEL. NUMBER*

DATE OF LOSS / DAMAGE*

TIME OF LOSS / DAMAGE*

:

DESCRIPTION OF PROPERTY

FROM WHOM PURCHASED OR ACQUIRED

DATE ACQUIRED

VALUE (R)

PLEASE SUPPLY A QUOTATION FOR ITEM/S CLAIMED

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Since its founding in 1955 LIIB, a fully fledged risk advisory and insurance intermediary.

Member of the i capital Group

1st Floor, 33 Scott Street
Waverley
Johannesburg, 2090

Member Euribron, a leading international network of independent insurance brokers