Property Loss / Damage Claim Form

"*" indicates required fields

1INSURED

2DESCRIPTION OF LOSS

3PAYMENT METHOD

4STATEMENT OF PROPERTY LOST, STOLEN OR DAMAGED

5DECLARATION

INSURED

POLICY NUMBER

Your Email Address

Please enter your email if you would like a copy.

Name and occupation*

Address and (day) telephone number

LOSS / DAMAGE OCCURRENCE

Date and time of loss / damage

When was loss / damage discovered?*

LOSS / DAMAGE PLACE

Place where loss / damage occurred?

Were premises occupied? By whom?

If not occupied, when last occupied?

Purpose of occupation

CAUSE OF LOSS / DAMAGE

Describe fully how the loss or damage occurred stating how (if applicable) entry was gained to premises.*

If loss/damage was caused by another party give name and address.

PREVIOUS LOSS / DAMAGE

Have you previously suffered loss/damage?*

If so, give details.

If insured, provide name of insurer

POLICE

Police reference number and station and date reported.

OTHER INTEREST

Has any other party an interest in the insured 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

When last valued?

PAYMENT METHOD

You may select for added security, payment of any amount due to you directly into a bank account. Please specify the name of the bank, branch, name of account and account number.

Name of Bank

Name of Account

Branch

Account Number

STATEMENT OF PROPERTY LOST, STOLEN OR DAMAGED

N.B. - Claims in respect of damage to buildings must be accompanied 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

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

DD slash MM slash YYYY