Property 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
Timeof appointment
access_time
Location
What was the cause of damage?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 and/ or Fire Authority?
To whom was it reported?
Date of Notificationfor Police
date_range
Stationfor Police
Reciept No.for Police
Date of Notificationfor Fire
date_range
Stationfor Fire
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
Building Sum Insured
Is the property repairable?
Is the property leased or mortgaged?
Name & Address of MortgageeSeparate by comma
0 /
Are there any other insurances upon the same property?
Name of Insurers and Policy Numbersif known
0 /
Upload Documents
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​Declaration *

I declare that the property detailed overleaf and insured the above policy was destroyed or damaged as stated and in consequence a claim is hereby made for the sum or sums stated herein and further declare that no other person except

Enter name

has any interest in the said property.


Important: This form should be completed and forwarded to the Company as soon as possible and in no case later than thirty (30) days from the date of the occurrence. Claimants are advised to read the Conditions of the Company’s policies regarding claim before completing this form.

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