CLAIM FORM Motor Claim Form Fire Claim FormAll Risk Claim Form All Risk Claim Form ALL RISK CLAIM FORM Policy Number Claim Number Insured’s Name in full Address Occupation Telephone Number Email Address Inception date / Renewal date Nature of Loss Describe the full circumstances of the loss, stating the date and time Do you suspect any person in connection therewith? The date police was advised and the address of the station What other steps have been taken to recover the property? Please give full details Are there any other insurances against this loss? PARTICULARS OF CLAIM No. of Article Full Description Name and address of seller Date of purchase Cost Paid Amount of Claim Special Notice: By the conditions, the policy is rendered void if any claim be fraudulent or intentionally exaggerated or if any false statement or declaration be made in support of it. It is therefore important that this form be filled with great care. I hereby declare that the within mentioned money / property (ies) belonging to me and insured under the said policy was lost, damaged or stolen in the circumstances stated and that in consequence thereof a claim is hereby being made for the sums severally stated within. Witness Signature Date NB: This statement of claim should be completed and forwarded immediately to the Company. The insured must at once take every practical and reasonable step that may lead to the recovery of money/property(ies). The police must be advised immediately and any suspicious deal as to the parties implicated must be communicated to the company without delay. Should any of the insured’s money / property which is the subject of this claim be recovered either before or after the indemnity has been provided under the within named policy, the Company must be notified immediately. Submit Claim Fire / Material Damage Claim Form FIRE / MATERIAL DAMAGE CLAIM FORM Policy Number Claim Number Name of Insured Address Occupation Telephone Number Email Address Inception Date Branch or Agent to whom premium was paid Trade / Occupation (state all, if more than one) Situation of the Premises affected / damaged Proximate Cause of loss / incident Date of incident / loss Details of how the incident occurred Have you ever lodged or reported a claim or claimed against any insurer on the risk insured? If so, give details: Are you the sole owner of the destroyed / damaged property? -- Select -- Yes No If no, state the name(s) of other interested parties and the nature of their interest: In respect of damage to buildings or landlord’s fixtures (including internal decoration), are you responsible for repair of such damage under the terms of a tenancy agreement? -- Select -- Yes No Was there at the time of the occurrence of loss any other existing insurance effected by you or any other person(s) on the property for which this claim is being made? If so, please give details In view of the nature of loss / incident, is there going to be salvageable items? -- Select -- Yes No If yes, is the insured or property owner interested in keeping same? -- Select -- Yes No Any damaged property(ies) or items should not be disposed off without intimating the insurer or getting insurer’s approval / permission. Details of claim and estimation Particular of each building or factory or article in respect of which this claim is made Date of construction or purchased or received Name of the Contractor/ from whom purchased or donated Original cost price Value at the time of fire destruction after given allowance for aging, wear and tear Present reinstatement cost Amount claimed after given allowance for value of salvage or cost of repairs Total Amount Claimed SPECIAL NOTICE : Going by the policy terms and conditions, the claim request could be rendered void if any claim is found to be fraudulent or intentionally exaggerated or if any false statement or declaration is made. It is therefore important that this form should be completed with great care. I / We declared the foregoing particulars to be true representation of the incident that happened. Signature of the insured: Date: *(If corporate, give status of the signatory) * Submit Claim Motor Accident Claim Form MOTOR ACCIDENT CLAIM FORM Policy Number Claim Number Name of Insured Address Occupation Telephone Number Email Address Inception Date Branch Insured Particulars (Vehicle) Make Reg. No. C.C Year of Make Engine No. Chassis No. Value of the Vehicle Purpose of Use Driver at the time of Accident Name Age Address Is Driver’s License in force -- Select -- Yes No If yes, which category Driving License Number Has it been endorsed -- Select -- Yes No Date of Issuance Place of Issuance Date of Expiry Is it a Learner’s permit -- Select -- Yes No If so, state number and Period Relationship of driver to the insured If paid driver, for how long Does the driver own a vehicle -- Select -- Yes No If so, name and address of the insurer Information on Accident Date Time Exact Location Road Condition Weather Condition Speed of the Vehicle Brake Condition Direction of Collision if applicable Address of Police Station where Accident was reported Number of Person(s) in: (i). Insured’s vehicle (ii). Third party’s vehicle Any injury sustained by the insured Full Description of Accident Witness Name and Address 1. Name and Address 2. Name and Address 3. Name and Address 4. Details of damaged parts Rough Estimate of Repairs Present Location of Vehicle Repairer’s Name and Address Details of Third Party Name(s): Address: Nature of Property: If vehicle; Make, model, Reg No. and year of make
