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SUBMIT A CLAIM

INSURED

Region:

Name:

Address:

Cell No:

Tel No:

Fax No:

Email:

ID No:

VAT No:

LOSS/DAMAGE OCCURANCE

Date and Time of loss/damage:

When was loss/damage discovered?:

LOSS/DAMAGE PLACE

Place where loss/damage occurred:

(a)Were premises occupied?:

(b)By Whom?:

If not occupied when last occupied?:

Purpose of occupation: e.g. 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?:

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, e.g. Credit agreement:

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:

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
				Add

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ASSURANCE

While personal and business insurance products protect your physical assets, assurance policies are designed to financially safeguard you, your loved ones and – if you’re a business owner or manager – your employees. One type of cover is for possessions; the other for people. Both are crucial to minimising worry so you can focus on the things that make life worth living.

For more information, please contact us.

Our assurance products are available for both private and commercial clients, and include:

Dread Disease Cover
Buy & Sell Agreements
Key Person Insurance
Disability Cover
Life Insurance
Investments
Employee Benefits Insurance
Retirement Annuities
Company Medical Aid
Private Medical Aid

To speak to one of our brokers, contact us on 031 242 6800, or fill in the Request a Quote form.

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ASSURANCE

For more information, please contact us.

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