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Date and Time of Loss*

Personal Details

Provide your policy number and personal details for us to process the claim.

Policy No*

Postal Address

Postal Code

PIN No.

City/Town

Technical Details

Provide information about your claim and the loss/damage.

How did the Loss Occur?*

Details of Other Party

Name*

Mobile No*

Has any other party had an interest in the insured property e.g. Credit Agreement?*

Yes

If so, give name and interest*

Place where Loss/Damage occurred

Were premises occupied?*

Yes

If so, by whom?*

Purpose of Occupation*

If not occupied, when last occupied?*

Have you previously suffered Loss/Damage?*

Yes

If so, give details*

If insured, provide name of insurer*

Is there any other insurance covering this Loss/Damage?*

Yes

Police Station

Date and Time of Report

Estimated total value of all the property insured under the policy at the time of loss/damage*

Payment Method

You may select, for added security, payment of any amount due to you directly into a bank account. Please specify the name of the bank, branch, name of account holder, account number and type of account.

Name of Bank*

Branch

Type of Account

Name of Account Holder*

Account Number*

Other Insurer(s)*

Particulars of Claim

Property List*

Declaration*

I/We declare that these particulars are true and correct and undertake to forward immediately (and unanswered) any correspondence relating to this accident/incident.

Was the loss caused by another party?*

Yes

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General Claim Form

Particulars of Claim

Personal Details

Technical Details

Details of Other Party

Loss/Damage Place

Previous Loss/Damage

Other Insurance

Police

Value

Payment Method

Particulars of Claim

Declaration