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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
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MOTO HEALTH CAREMEDICAL AID INSURANCE

Moto Health Care is a Bargaining Council Fund registered with the Council for Medical Schemes in October 2007. The Fund is restricted to Employers and their employees operating in the Motor Industry in South Africa. The Fund is managed by a Board of Trustees, made up of Parties to the Moto Health Care Agreement with the Motor Industry Bargaining Council (MIBCO).

For more information on Moto Health Care Medical Aid, click here.

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MOTO HEALTH CAREMEDICAL AID INSURANCE

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