Estimated Total value of all property insured
Is there any other insurance
Covering loss / damage?
If so, give name of Insurer
Occupation of Insured
Date & Time of loss / damage
Address where loss / damage occurred
Were premises occupied & by whom
If not occupied, when last occupied
Purpose of occupation
Describe fully how the loss or damage occurred & if applicable how entry was gained to the premises
Was Burglar Alarm activated?
If Loss / damage was caused by another
party, Give name & address
Have you previously suffered loss / damage
Any other party interest in the property?
If Yes, give name of insurer
If Yes, give name and interest
When was loss discovered
Police Reference Number and Station
Name of Insured
When last valued?
CLAIM FORM: PROPERTY LOSS / DAMAGE
PO Box 5855, TygerValley 7536
0861 242 123
086 520 0920
Associated Insurance Brokers Cape 2006 (Pty) Ltd
Reg No 2005/026692/07 Licensed financial services provider (No 31032)