ANSWERS
QUESTIONS
Policy Number
Estimated Total value of all property insured
Is there any other insurance
Covering loss / damage?
If so, give name of Insurer
Address
Occupation of Insured
Tel. No.
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
Date Reported
Name of Insured
When last valued?
YES NO
YES NO
YES
YES NO
NO
Home:|
Work:| Cell:|
CLAIM FORM: PROPERTY LOSS / DAMAGE
PO Box 5855, TygerValley 7536
Tel:
Fax:
email:
0861 242 123
086 520 0920
claims@aib.co.za
Associated Insurance Brokers Cape 2006 (Pty) Ltd
Reg No 2005/026692/07 Licensed financial services provider (No 31032)
Capacity:
Date:
Insured Signature
PAGE 2
Name of Bank
Branch & Code No.
Account No.
Account Type
Name of account Holder
It is recommended that if any amount is payable directly to you, it be transmitted by Electronic Bank Transfer for speedier settlement and
security reasons. If you are agreeable to this, please complete and provide the following information
INSURED’S BANKING DETAILS
PROPERTY LOSS / DAMAGE CLAIM FORM
I / We hereby declare that the above and foregoing particulars to be true in every aspect
I / We have suffered loss of or damage to the property enumerated on page 3 hereof and that
the said property was in my / our possession immediately prior to the said loss / damage which
occurred in the circumstances described above.
CLAIM FORM: PROPERTY L
OS
S / D
AMAGE
N.B. Claims in respect of damage to buildings must be accompanied by a builders estimate
P
AGE 3
Description Date
Acquired
From whom
purchased or
acquired
Current
replacement
value
Deduction for wear
and tear or
depreciation (if
applicable or value
of salvage)
Number
Amount Claimed
PO Box 5855, TygerValley 7536
T
el:
Fax:
email:
0861 242 123
086 520 0920
claims@aib.co.za
Associated Insurance Brokers (Cape) 2006 (Pty) Ltd
Reg No 2005/026692/07 Licensed financial services provider (No 31032)
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