GENERAL LOSS CLAIM FORM
   
INSURED

 
Name:    
Address:    
Cell: Telephone No:
Fax No: Email Address:
Id No: Vat No:
   
LOSS/DAMAGE OCCURRENCE
Date and time of loss/damage:
When was loss/damage discovered?:
   
LOSS/DAMAGE PLACE
Place where loss/damage occurred:

(a)Were premises occupied?: Yes No
(b)By Whom?:
If not occupied when last occupied?:
Purpose of occupation: Office Space
   
CAUSE OF LOSS/DAMAGE
Describe fully how the loss or damage occurred stating how (if applicable) entry was gained to the premises:
If loss/damage caused by another
party give name and address:
   
PREVIOUS LOSS/DAMAGE
Have you previously suffered a loss/
damage?:		 Yes No
If so, give details:
If insured, provide name of insurer:
   
POLICE

  
Police Station:
Reference Number:
Date Reported:
   
OTHER INTEREST
Has any other party an interest in the
insured property, eg, Credit
agreement:		 Yes No
If so, give name and interest:
   
OTHER INSURANCE
Is there any other insurance covering
this loss?:
If so, give name of insurers:
   
VALUE

  
Estimated total of all the property,
insured under the policy:
When last valued?:
   
PAYMENT METHOD
Name of bank:
Branch:
Account Holder:
Branch Code:
Type of account:
Account number:
   
DECLARATION
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 possession immediately prior to the said loss/damage which occurred in the circumstances described above.
   
Signature: :  
   
Qty DESCRIPTION OF PROPERTY DATE ACQUIRED PURCHASE PRICE AMOUNT CLAIMED