Broker Name and Branch:
Occupation or type of Business:
Date and Time of Loss/Damage:
When was the Loss/Damage Discovered?
Place where Loss/Damage Occured:
Were Premises Occupied, And by whom?
If not Occupied, when last occupied?
Purpose of Occupation:
Describle fully how Loss/Damage occurred, stating how (if applicable) entry was gained to the premises:
If Loss/Damage caused by another party, give name and address:
Have you previously suffered a Loss/Damage?
if so, provide details:
If Insured, provide name of Insurer:
Has any other party an interest in the property insured?
If so, provide details:
Is there any other Insurance covering this Loss/Damage?
If so, Provide name of Insurer:
Estimated total value of all the property insured under the policy:
You may select, for added security, payment of any amount due to you directly into a bank account. Please specify the name, branch and account number.
Name of Bank:
Name of Account:
Name of Insured:
Send me a copy of this claim: