Property Loss / Damage Claim Form "*" indicates required fields 1INSURED2DESCRIPTION OF LOSS3PAYMENT METHOD4STATEMENT OF PROPERTY LOST, STOLEN OR DAMAGED5DECLARATION INSUREDPOLICY NUMBERYour Email Address Please enter your email if you would like a copy.Name and occupation*Address and (day) telephone number LOSS / DAMAGE OCCURRENCEDate and time of loss / damageWhen was loss / damage discovered?*LOSS / DAMAGE PLACEPlace where loss / damage occurred?Were premises occupied? By whom?If not occupied, when last occupied?Purpose of occupationCAUSE OF LOSS / DAMAGEDescribe 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 / DAMAGEHave you previously suffered loss/damage?*YesNoIf so, give details.If insured, provide name of insurerPOLICEPolice reference number and station and date reported.OTHER INTERESTHas any other party an interest in the insured property, e.g. Credit Agreement?*YesNoIf so, give name and interestOTHER INSURANCEIs there any other insurance covering this loss/damage?YesNoIf so, give name of insurerVALUEEstimated total value of all the property insured under the policyWhen last valued? PAYMENT METHODYou 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 BankName of AccountBranchAccount Number STATEMENT OF PROPERTY LOST, STOLEN OR DAMAGEDN.B. - Claims in respect of damage to buildings must be accompanied by a builder's estimate. PROPERTY LOST, STOLEN OR DAMAGEDDescription of propertyDate acquiredFrom whom purchased or acquired.ValueDeduction for wear and tear, or depreciation or value of salvageAmount Claimed Add Remove 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 DD slash MM slash YYYY
