Claim Forms

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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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Name:

Email:

ID No/Company Reg No:

Address:

Policy No:

* Please note that your policy will be sent through once email is received.

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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:

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

Signature:

QTY	Description of Property	Date Acquired	Purchase Price	Amount Claimed
				Add

GLASS CLAIM FORM

	INSURED
	Region:
	Name:
	Address:	Occupation:
	Cell No:	Tel No:
	Fax No:	Email:
	ID No:	VAT No:

	LOSS/DAMAGE OCCURANCE
	Date and Time of loss/damage:
	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:
	Name:
	Address:	Occupation:
	Cell No:	Tel No:
	Fax No:	Email:
	ID No:	VAT No:

	PARTICULARS OF ACCIDENT
	Date and Time of accident:

	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:
	Name:
	Address:	Occupation:
	Cell No:	Tel No:
	Fax No:	Email:
	ID No:	VAT No:

	LOSS/DAMAGE OCCURRANCE
	Date and Time of accident:
	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?	AfloatOn a Mud BerthHauled 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:

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:

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:
	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:
	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:
	Place of Theft:
	Police Station:
	Police Reference:
	Date Reported:
	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:
	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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