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BURGLARY CLAIM FORM
The issue of this Form is NOT an admission of liability on the part of the Company
State the number of your Policy
State date of payment of last premium
State the date and time when the loss occurred
date
time
State the date of discovery and by whom Discovered
date
by whom
State address and description of the premises where the loss occurred. Say whether Private Dwelling House, Maisonette, Flat, Apartments, Boarding or Lodging House. If Flat say whether self- Contained or not.
address
description
type
State part of the premises from which the Property was stolen.
Are you the sole owner of the stolen or Damaged property described overleaf?
yes no
State whether the premises were unoccupied at the time of the loss. If unoccupied, how long Had they been so?
occupied unoccupied
how long
State whether the premises or any part thereof were lent, let or sub-let at the time of the loss.
How was entry to premises effected? Give full details.
State (a) date loss notified to the Police and
the name and address of the Police Station
name
address
Have you any suspicious as to parties implicated? If so, give full details
yes no
details
At the time of the loss what was the total value of the whole contents of premises?
State amount for which you have insured the contents of the premises against Fire and name of Company.
Is the property claimed for insured with any other Company or with Underwriters against Burglary, Housebreaking, Larceny or All Risk? If so, give full particulars including name of insurers and Policy number.
yes no
details
14. Have you previously suffered a loss by Burglary, Housebreaking or Theft? If so, give full particulars.
yes no
details
Have you ever made a claim against any Insurance Company or Underwriters under a Burglary or All Risks Policy? If so, please give full particulars.
yes no
details
I do solemnly declare that the Property described on the other side, belonging to me, and under the said Policy, was stolen or damaged, and that the amounts severally stated represent the sum I am entitled to claim, in terms of the Policy. I also further declare that no other person has an interest in the said Property, whether as Owner, Mortgaged. Trustee or otherwise that it is not otherwise insured against All Risks, Burglary, Housebreaking or Theft with this or any other Office or with Underwriters, except as hereinmentioned, that I have not withheld any material information and that all the statements on this form are to the best of my knowledge and belief correct.
do you agree
yes no
STATEMENT OF CLAIM
FULL DESCRIPTION OF PROPERTY STATE TO WHOM PROPERTY BELONGED WHERE AND WHEN BOUGHT COST PRICE DEDUCTIONS FOR DEPRECIATION AND/OR WEAR AND TEAR AMOUNT CLAIMED


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