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Please complete this form and your Brokersure claims person will be in contact with you shortly

Geyser Claim Form

Hi, I'm George, let's team up and complete this together.

Your Particulars

Address where the geyser burst
Address where the geyser burst
Is there any resulting damage e.g. water damage to the ceiling?

Maximum file size: 33.55MB

Warrantee and Signature

By completing and submitting this form electronically you warrant to the following:

I have suffered a loss to the property described or uploaded via this website.

The information that I have provided is true.

If any part of this claim, or the information provided, is false or fraudulent that I will not be entitled to any benefits.

If I have deliberately caused the loss that I will not be entitled to any benefits.

I confirm: