Burglary Claim Form

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Insured Details
Policy Holder’s Name
Address
Cellphone
Homephone
Insured Details
Policy No.
Effective Date
date_range
Expiry Date
date_range
Risk Address
Loss Details
Date
date_range
Time
access_time
Location
Do you suspect any particular person?NB in cases of fire, the exact cause of the outbreak should be clearly stated.
0 /
Was the Loss or Damage reported to the Police?
Date of Notificationfor Police
date_range
Stationfor Police
Reciept No.for Police
Loss History
Have you had any previous Loss or made any claims for loss, theft or damage on any Insurer in the past 5 years?
Please state Name of Insurers and Policy NumbersIf known
0 / 500
Premises Information
When were the premises last occupied?
date_range
Time
access_time
Were the premises securely locked?
How was entry gained?
Is the any other occupier of the premises?
Statement of Loss
Sum Insured
Are you the sole owner of the stolen property?
State Name and Address of owner/sSeparate by comma
0 /
Are there any other insurances against this loss?
Name of Insurers and Policy Numbersif known
0 /
Upload Documents
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​Declaration *

I / We agree that if I/We have made or in any further declaration the Company may require in respect of the said incident, shall make any false or fraudulent statement, or any suppression or concealment, my/our claim shall be absolutely forfeited and the Policy shall be null and void and all rights to claim/recover there-under in respect of past or future loss/ incidents/accidents shall be forfeited

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