Bryte Property Loss / Damage Claim 1Insured2Loss/Damage3Cause of loss/damage4Other5Payment method6Declaration7 List Add RemoveBroker/AgentPolicy numberID numberEmail Please enter your email if you would like a copy.InsuredName and occupationAddress and (day) telephone number Loss/Damage occurrencesDate and time of loss/damageWhen was loss/damage discovered?Loss/damage placePlace where loss/damage occurredWere premises occupied? Yes No If yes, by whom?If not occupied, when last occupied?Purpose of occupation Cause of loss/damageDescribe fully how the loss or damage occurred stating how (if applicable) entry was gained to premisesIf loss/damage was caused by another party give name and addressPrevious loss/ damageHave you previously suffered loss/damage? Yes No If yes, give detailsIf insured, provide name of insurerPolicePolice reference number, station and date reported Has any other party an interest in the insured property, e.g. credit agreement? Yes No Is there any other insurance covering this loss/ damage? Yes No If so, give name of insurerEstimated total value of all the property insured under the policyWhen last valued? Payment methodYou may select, for added security, for payment of any amount due to you to be made directly into a bank account. Please specify the name of the bank, branch, name of account and account number.Name of bankBranchName of accountAccount number DeclarationI/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 signatureCapacityDate MM slash DD slash YYYY Protection of Personal Information Act (POPIA)All personal information collected on this form will be processed in accordance with our privacy statement. https://www.brytesa.com/pdf/Bryte_privacy_statement.pdf Signed atDayMonthYearSignature of policyholder Statement of property lost, stolen or damagedN.B. Claims in respect of damage to buildings must be accompanied by a builder’s estimate. Insurers share information with each other regarding domestic policies and claims with a view to prevent fraudulent claims and obtain material information regarding the assessment of risks proposed for insurance. Please refer to the Consent Clause on the policy schedule for more details in this regard.Statement of property lost, stolen or damagedNumberDescription of propertyDate acquiredFrom whom purchased or acquiredValueDeduction for wear and tear or depreciation or value of salvageAmount claimed Add Remove
