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General Loss Claims Form

We care about your privacy. In order to provide you with our service, we and our service providers have to process the personal information you provide us with by completing this General Loss Claims Form. We will treat this information with caution and we have put reasonable security measures in place to protect it.

CUSTOMER DETAILS

Customer Declaration

Name

Surname

Phone Number

Email Address

Capacity

Date

Customer & Policy Information

Broker/Agent

Policy Number

VAT Reg. Number

Name and Occupation

Address

Bank Details (for payout)

Bank Name

Branch

Account Name

Account Number

LOSS DETAILS

Loss / Damage Details

Date of Loss

Time of Loss

Date Discovered

Place of Loss/Damage

Premises Occupancy

Were premises occupied?

YesNo

If so, by whom

Purpose of occupation

If not, when last occupied

Describe fully how the loss/damage occurred

Alarm & Third-Party Info

Was the alarm activated prior to the incident?
YesNo

Have you requested the alarm report?
YesNo

Was another party responsible?
YesNo

If yes, name and address

Previous Losses & Other Insurance

Have you previously suffered loss?
YesNo

If yes, provide details

Is any other party interested in the insured property?
YesNo

If yes, name and interest

Is there any other insurance covering this loss?
YesNo

If yes, name of insurer

Police Report

Police Station

Police Reference Number

Date Reported

LOSS ITEMS

Statement of Property Lost, Stolen or Damaged

LOSS ITEM

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Description

Date Acquired

From whom acquired

Value (R)

Amount Claimed (R)

Upload Supporting File

I/We warrant that the answers given are true and correct. All details provided are done so honestly and in good faith.

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