TEST – PROPERTY LOSS / DAMAGE CLAIM FORM

AANSTELLING OM FINANSIËLE DIENSTE TE LEWER

POLICY NUMBER

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Versekerde
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Address
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Day telephone number
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Date and time of loss/damage
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When was loss/damage discovered?
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Place where loss/damage occurred
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Were premises occupied?
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By whom?
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If not occupied, when last occupied?
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Purpose of occupation
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Describe fully how the loss/damage occurred stating how (if applicable) entry was gained to premises
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Have you previously suffered loss/damage?
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If so, give details
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If insured, provide name of insured
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Police reference number and station and date reported
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Has any other party an interest in the insured property, e.g. credit agreement?
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If so, give name of insurer
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Is there any other insurance covering this loss/damage?
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If so, give name of insurer
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Estimate total value of all the property insured under the policy
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When last valued?
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You may select, for added security, payment of any amount du to your directly into a bank account. Please specify the name og bank, branch, name of account end account number.

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Name of Bank
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Name of Account
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Branch
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Account number
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I/We solemnly declare that I/We have suffered loss/damage to the property enumerated on the reverse hereof and that the sad property was in my/our possession immediately prior to the said loss/damage which occurred in the circumstances described above.

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Insured’s signature
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Capacity
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ID number
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N.B – Claims in respect of damage to buildings must be accompanied by a builder’s estimate.

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Number
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Description of property
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Date acquired
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From whom purchased or acquired
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Value
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Deduction for wear and tear or depreciation or value of salvage
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Amount claimed
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Submit