Fire Claims

New Other Insurance Claim Form

Policy (or Certificate) No

Branch or Agent to whom you Paid your last premium

Email Address

A. Insured

Name

Address (Private)

Telephone No (Private)

Address (Business)

Telephone No (Business)

Trade or Occupation (if more than one state all)

B. Circumstances

Date of Loss

Time of Loss

Describe briefly what happened and the resultant damage and state what you believe was the cause of the damage

C. Please Give the following information about your premises

For what purposes were the premises being used as at date of occurrence

Were the Premises and their occupation at the time of the occurrence exactly as described in the policy?

Had element of risk been introduced which was not allowed by the policy?

Is the owner the sole owner of the property damaged or destroyed? If not, state full particulars of any interested parties

D. Please give the total value of the contents at the time of loss

Was Police /Fire Brigade informed? If yes,please enclose the report

Who has witnessed the loss?

What measures was taken to mitigate the loss?

Give details of any previous claims of a similar nature you have made?

Statement of Claim

Description of Property Destroyed or Damage

If damaged state nature of damage

Belonging to

Date of Purchase

Place of Purchase

Price Paid

Deduction for age, use wear and tear

Amount claimed

Who we are

Initiatives

Working With Us

Financials

Investors

New Other Insurance Claim Form

A. Insured

B. Circumstances

C. Please Give the following information about your premises

D. Please give the total value of the contents at the time of loss

Statement of Claim

Claims Form

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