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Household claim form
Particulars of claim
Please complete fully and submit so that your Insurers can consider your claim.
Policy Number
Name of insured
Telephone
Email
Is your address business or private?
Business
Private
Claim address
1.
(a) State whether the property was burnt, stolen, lost or damaged
Burnt
Stolen
Lost
Damaged
(b) If stolen, do you suspect anyone, and if so whom?
(c) If stolen or lost, when was the property last seen by you, and where?
2.
(a) Date of loss
Time of loss
(b) Describe circumstances under which loss took place.
3. Are you the sole owner of the property? If not, give name of owner.
4. If the property was stolen or lost give the date Police were advised, and name of Station. (Police must be advised promptly)
5. Are there other insurances covering any of the property?
6. Value Added Tax: Are you registered as a Taxable person? If yes, state % remission of input tax obtainable.
7.
• Please provide a full description of articles lost, stolen or damaged
• When and where purchased, and cost
• Replacement cost
• Deduction for depreciation
• Amount claimed
Items
8. Upload Estimates/Receipts wherever possible to avoid delays
9. To whom should cheque be made payable to?
I/We declare that the above information is true and complete to the best of my/our knowledge
Signature
❌
Date
Send
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