Particulars of Insured

    Broker Name and Branch:

    Policy Name:

    Occupation or type of Business:

    Email Address:

    Cellular Telephone Number:

    Loss or Damage Details

    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:

    Police Station:

    Case Number:

    Date Reported:

    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:

    Payment Method

    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:


    Declaration and Signature

    I/we solemnly declare that I/we have suffered loss of or damage to the property enumerated and that the said property was in my/our possession immediately prior to the said loss/damage which occurred in the circumstances described above.

    I/we the undersigned, declare the aforegoing particulars to be true in every respect. We understand that we will not be entitled to any benefits or indemnification of this claim, if the claim submitted is fraudulent in any manner whatsoever, whether submitted by ourselves or any of our agents.

    Name of Insured:


    Send me a copy of this claim:


    Click to confirm: