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    All fields with * are Mandatory


    Personal Information
    Vat No.*
    Branch/Agency*
    Claim No.*
    Policy No.*
    1
    First Name of Insured*
    Last Name of Insured*
    Address*
    Profession or Occupation *
    Country Code *
    Telephone No. *
    Country Code *
    Cell No. *
    Email address: *
    Confirm Email:*
    2
    (a)(i)Date when the loss or damage occurred*:
    (ii)Time when the loss or damage occurred*:
    (b)(i)Date when the loss or damage was discovered*:
    (ii)Time when the loss or damage was discovered*:
    (iii)By whom was the loss or damage discovered?*:
    (c)(i)Date when the property lost or damaged was last seen*:
    (ii)Time when the property lost or damaged was last seen*:
    (iii)Whom was lost or damaged was last seen by*:
    (d) Address of premises where loss or damage occurred*:
    3
    Please give the full particulars of the manner and circumstances of the loss or damage*:
    4
    (a)(i)Has the loss been reported to the Police*:YesNo
    (ii)If so, state when and the name and address of the Police Station?*:
    (b) What other steps have been taken for the recovery of the property lost?*:
    5
    If the loss is in respect of Jewellery, when was it last overhauled by a Jeweller?:
    Give the name and address of the Jeweller:
    6
    (a) Have you previously sustained any loss or damage to property?*:YesNo
    (b) Was a claim made upon any Company or Underwriter?*:YesNo
    (c) If so, give name and date, nature of loss or damage and amount paid?:*
    7
    (a)Are there any other Insurances upon the property?*:YesNo
    (b)If so, please give full particulars?:*
    STATEMENT OF CLAIM
    Please complete each column in respect of each article lost or damaged:-
    Description of article lost or damaged To whom does the article belong? Name and address of person from whom the article was purchased or by whom presented Date of purchase, or gift and price paid Deduction for wear and tear,depreciation and age Amount claimed