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 FIRE INSURANCE CLAIM FORM

CLAIM NO

The issue of this form is not to be considered as an admission of liability on the part of the Company.
POLICY NO DATE OF LAST PREMIUM
I/We   of    carrying on the business of    being insured
under Policy No.     do hereby declare and set forth that on or about   o’clock a. m./p. m. on
the    day of    a Fire occurred in    at
  occasioned, to the best of my/ourknowledge and believe by 

And I/we further declare that the Property mentioned on the other side, and insured under the item of the Policy of EXECUTIVE INSURANCE COMPANY LIMITED, was destroyed or damaged by the said Fire to the extent of the amounts there specified.

I/We also further declared that *

* Here state the nature of your interest, whether sole owner, or holding the property in trust or on commission or otherwise of the Property referred to above, and that it is not otherwise insured in EXECUTIVE INSURANCE COMPANY LIMITED or any other insured except as stated overleaf.

When a fire occurs the insured is, within fifteen days after, at the latest to deliver to the company an account of the several articles of matters damaged or destroyed by fire with the estimated cash value of each of them respectively immediately before the fire. When property hereby insured is only partially damaged by fire no abandonment thereof will be allowed unless by consent of the company or its agents.

The cash value of property destroyed or damaged by fire shall in no case exceed what would be the cost to the insured of replacing the same; and incase of the depreciation of such property from use, or otherwise, a corresponding deduction shall be made from the cost of replacement in order to ascertain the actual cash value immediately before the fire.

CAUSE OF FIRE – To be stated as explicitly as possible, and, where the cause is undiscovered, any suspicion of incendiarism to be mentioned.

THE FOLLOWING PARTICULARS ARE REQUIRED WHEN THE CLAIM RELATES TO:

  1. BUILDING:

(A.)      A builder’s or architect’s estimate (obtained at the expense of the insured) giving dimensions and prices of the work required to place the building in the same state of repair as before the fire. No contemplated improvements to be included in the estimate.
            (B)       The insured to state whether he holds the property as sole or part owner, or otherwise.

  1. FURNITURE:
  2. A complete list of articles damaged or destroyed.
  3. Cost price of each and when and where bought.
  4. Value of each immediately before the fire, after deduction for past wear and tear,

depreciation e. t. c.

  1. Value of salvage.
  2. GOODS AND MERCHANDISE
  3. List of articles damaged or destroyed
  4. The price of each according to the market value of the goods immediately before the fire.
  5. Value of salvage.
  6. N. B. - When the policy is subject to the average or pro rata condition a full and exact statement of the whole value of the property within the protection of the policy, or of the item(s) under which the claim is made must be furnished.

In cases where the loss is only a trifling one and the Agent has been able to satisfy himself as to the accuracy of the claim without the intervention of an Accessor, the former should state this over his signature.

FOR DETAILS OF CLAIM SEE OTHER SIDE
NAME OF AGENT DATE
ADDRESS BRANCH
VOUCHER NO. AGENCY NO.
DATE POLICY NO. NAME OF INSURED RECEIPT NO. RATE PREMIUM COMMISSION
RECEIVED THE SUM OF PREPARED BY
CHECKED BY AUTHORISED BY
DATE    
 


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