Submit Theft Claim

Claim Form

Name of insured ^*

Full name separated by space

Policy No ^*

Occupation

Residential/Business Address ^*

Contact No ^*

Date of loss ^*

Time

Discovered By

Date reported to the police ^*

Police station number?

Reported by

Has the police investigated the loss?

YES NO

Are you the sole owner of the damaged property?

YES NO

Are there any other insurances in force upon the same property?

YES NO

If so please state the name of insurer

Have you ever had a previous loss by the perils ensured?

YES NO

If so please give details and name of insurer

Stolen From..^*

Name of Owner

Address

Type of property

Extent of damage

Registration number

Is insured?

YES NO

Insurance Company

Description of articles (please state serial numbers or any other identifying marks)	Date and Place of purchase	Price paid	Replacement price	Deduction for depreciation	Amount claimed