Account No.
Policy No :
Branch or Agent :
Claim No :
Name :
VAT No :
Address :
Telepone No :
1. When did the damage take place? Date : Time :
2. (a) Address of the premises where the damage occurred.
(b) Name of Occupant if not Insured
(c) Construction of Premises :
3. (a) For what purpose (e.g Private dwelling, Shop, Factory, etc.) were the premises occupied at the date of the damage.
(b)If any alteration in risk had taken place since policy was issued or last endorsed please give details.
4.What was the cause of the damage, and how did it occur?
5.(a)Does the property in respect of which the claim is made belong solely to you?
(b) If not, please give full name of any other party interested therein.
6. (a) Are there any other insurances on the property, whether effected by you or by any other party?
(b)If so, please give name of Company, Policy No. and amount insured, if known.
7. (a) Have you previously suffered loss from a similar cause in these or other premises?
(b) If so, please give details
I/We do hereby declare that the above is a full, true and accurate statement, and I/we further declare that the property mentioned on the reverse hereof, which belongs to me/us and which is insured under the above-named Policy or Policies, was destroyed or damaged as aforesaid according to the extent and values stated; wherefore I/we claim the sum of the amount thereof.
Full name of insured :
Date :
BUILDINGS : The Claim should be by a Trademan’s Estimate, obtained at Insured’s expense of the cost of putting the Building into the same state as it was in immediately before the damage; IMPROVEMENTS should not be included in such estimate.
CONTENTS : It is essential to give a full list of the articles destroyed or damaged, with the particulars set out below. In the case of stock the "estimated value immediately before the damage" (column 5) must not exceed the value before sale, i.e. it must not be, based on the selling price.
No. of Articles Description of Property or Articles destroyed or damaged Approx Date of Purchase Original Cost Price Estimated Value immediately before the damage allowing for "wear and tear" Estimated Value after the damage Amount claimed i.e. the difference between the last two columns