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INSURED
Region:
Select a Region
Kwa-Zulu Natal
Gauteng
Eastern Cape
Western Cape
Name:
Address:
Cell No:
Tel No:
Fax No:
Email:
ID No:
VAT No:
LOSS/DAMAGE OCCURANCE
Date and Time of loss/damage:
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When was loss/damage discovered?:
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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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Policy No:
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Claim Forms
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Claim Forms
General Loss Claim Form
Public Liability Claim Form
Motor Accident
Motor Theft
Bereavement Benefit Claim Form
GENERAL LOSS CLAIM FORM
INSURED
Region:
Select a Region
Kwa-Zulu Natal
Gauteng
Eastern Cape
Western Cape
Name:
Address:
Cell No:
Tel No:
Fax No:
Email:
ID No:
VAT No:
LOSS/DAMAGE OCCURANCE
Date and Time of loss/damage:
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When was loss/damage discovered?:
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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
GLASS CLAIM FORM
INSURED
Region:
Select a Region
Kwa-Zulu Natal
Gauteng
Eastern Cape
Western Cape
Name:
Address:
Occupation:
Cell No:
Tel No:
Fax No:
Email:
ID No:
VAT No:
LOSS/DAMAGE OCCURANCE
Date and Time of loss/damage:
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Cause of breakage
Name & address of person responsible, if applicable
Names & addresses of Witnesses
PREMISES
Address of premises where breakage occurred:
(a)Were premises occupied?:
(b)By Whom?:
Purpose of occupation: e.g. Office Space
VEHICLE
Model & year
Windscreen tinted or clear?
Drivers name and license details
DETAILS OF BROKEN GLASS
Cracked or shattered?
Any signwriting on broken glass?
If insured, provide name of insurer:
OTHER INSURANCE
Is there any other insurance covering the broken glass?
If so, give name of insurers:
PAYMENT METHOD
Name of bank:
Account Holder:
Branch Code:
Type of account:
Account number:
DECLARATION
I/We solemnly declare that the above particulars are true in every respect.
Signature:
PUBLIC LIABILITY CLAIM FORM
INSURED
Region:
Select a Region
Kwa-Zulu Natal
Gauteng
Eastern Cape
Western Cape
Name:
Address:
Occupation:
Cell No:
Tel No:
Fax No:
Email:
ID No:
VAT No:
PARTICULARS OF ACCIDENT
Date and Time of accident:
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Place of Accident
Exact place where accident occured
Explain exactly how the accident happened
THIRD PARTY
Name of person injured or owner of property damaged:
Address:
Age of person injured:
Details of injury:
Business or occupation:
Full details of personal injuries:
Damage of properties of third parties:
Have you made any offer to settle the claim in any way?:
OTHER INSURANCE
Have you any other insurance in force in respect of the occurrence? If so, give particulars
PROPERTY OWNERS (TO BE COMPLETED ONLY IF CLAIM IN UNDER PROPERTY OWNERS POLICY)
Name and address of your tennant
DRIVING ACCIDENTS (COMPLETE ONLY IF CLAIM UNDER A DRIVING ACCIDENTS POLICY)
Name of driver:
Age:
Address:
How long has he been in your employment?:
Was the driver injured?:
If so, give details:
Description of vehicle:
Was vehicle damaged?:
If so, give particulars/cost of repair:
Where can vehicle be examined?:
WITNESS
Name:
Address:
Tel No:
POLICE DETAILS (IF APPLICABLE)
PAYMENT METHOD
Name of bank:
Account Holder:
Branch Code:
Type of account:
Account number:
DECLARATION
I/We solemnly declare that the above particulars are true in every respect.
Signature:
MARINE CLAIM FORM
INSURED
Region:
Select a Region
Kwa-Zulu Natal
Gauteng
Eastern Cape
Western Cape
Name:
Address:
Occupation:
Cell No:
Tel No:
Fax No:
Email:
ID No:
VAT No:
LOSS/DAMAGE OCCURRANCE
Date and Time of accident:
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Where did accident occur?
Was vessel racing at the time?
Nature of accident with full details.
If the vessel was laid up at the time of accident was she Afloat, on a Mud berth or Hauled out?
Afloat
On a Mud Berth
Hauled Out
Who was in charge at the time of accident?:
Names and addresses of witnesses:
Where may the vessel be inspected?:
Details of any assistance rendered and the names and addresses of persons rendering it:
Is there any other Insurance (If so, give name of Insurer):
PAYMENT METHOD
Name of bank:
Account Holder:
Branch Code:
Type of account:
Account number:
DECLARATION
I/We solemnly declare that the above particulars are true in every respect.
Signature:
MOTOR ACCIDENT CLAIM FORM
INSURER
Name:
Policy No:
Claim No:
INSURED
Region:
Select a Region
Kwa-Zulu Natal
Gauteng
Eastern Cape
Western Cape
Name:
Address:
Occupation:
Cell No:
Tel No:
Fax No:
Email:
ID No:
VAT No:
VEHICLE
If vehicle is subject to hire purchase, credit or leasing agreement, state name, address and account number of finance company
Make:
Tare:
Gross Vehicle Mass:
Registration:
KM Completed:
Value:
Model and Year:
Purchase:
In whose name is the vehicle registered?:
LOSS/DAMAGE PLACE
Damage to own vehicle:
Estimate for repairs or attach quotation:
Repairer’s name, address and telephone number
Where can your damaged vehicle be inspected?
DRIVER
Full Name:
Residential Address:
Occupation:
Date of Birth:
ID Number:
Drivers Licence:
State fully the purpose for which vehicle was being used:
Was he/she driving with your permission?:
Yes
No
Was he/she in your employ?:
Yes
No
Has he/she any motor insurance on own car? If yes, state policy no. And company:
Details of any convictions for motoring offences:
Has license ever been endorsed?
Yes
No
Has he/she any physical defects?:
Yes
No
Details of previous accidents:
PASSANGERS
Passengers in insured vehicle
For what purposes were they carried?
Are they employees?
Yes
No
OTHER PARTY
Personal injuries (other than in insured Vehicles)
This accident must be reported to the multilateral motor vehicle fund using the special accident report form (mmf3) within 14 days if there is any likelihood of injuries, otherwise the fund may be able to recover from you. The fund’s address is PO Box 2743, pretoria 0001
Reg No
Make
Name & address of owner and driver
Details of Damage
Add
Name of Owner
Address of Owner
Details of Damage
Add
WITNESS
Name
Address
Details of Damage
Add
ACCIDENT
Date and Time:
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Place:
Speed before Accident:
Moment of Impact:
Weather Condition:
Visibility:
Road Surface:
Width of Road:
Which vehicle lights were on?:
Street lighting:
Yes
No
Was any warning given by you e.g. Hooting, indicators, etc?:
Name of police officer who recorded details of accident:
Police station & reference no:
Was the driver tested for alcohol or drugs?:
Yes
No
Description of Accident:
DECLARATION
We hereby declare the foregoing particulars to be true in every respect:
Signature:
MOTOR THEFT CLAIM FORM
INSURED
Region:
Select a Region
Kwa-Zulu Natal
Gauteng
Eastern Cape
Western Cape
Name:
Address:
Occupation:
Cell No:
Tel No:
Fax No:
Email:
ID No:
VAT No:
FINANCE COMPANY
Name:
Branch:
Account Number:
Type of Agreement:
VEHICLE
Make:
Model:
Year:
Registration Number:
KM Travelled:
Date of last service:
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VIN Number:
Chassis Number:
Engine Number:
Exterior Colour:
Interior Colour:
Registered Owner:
THEFT
Name of driver prior to theft:
Age:
Relationship to insured - If applicable:
Date & time of theft:
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Place of Theft:
Police Station:
Police Reference:
Date Reported:
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Reported By:
Circumstances:
Was alarm activated, if not give reasons:
Was the vehicle locked? If not give reasons:
ANTI-THEFT VEHICLE RECOVERY DEVICE DETAILS
Make:
Fitted By:
Date:
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Details of dents, scratches defects:
Stickers/Sign Writing?:
PAYMENT METHOD
Name of bank:
Account Holder:
Branch Code:
Type of account:
Account number:
DECLARATION
I/We solemnly declare that the above particulars are true in every respect.
Signature:
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