Home » Claims » Work Compensation Accident Claim

<% Else %>

MONEY INSURANCE CLAIM FORM

CLAIM NO

I/We   of    Being insured under Policy No    do hereby

declare that at or about   o’clock a. m./p. m. on the    day of

a loss occurred, occasioned, to the best of my/our knowledge and belief  in the following manner    

And I/We further declare that the money/Stamps overleaf, belonging to me/us, and insured under the Said policy, was/were lost/stolen and represent(s) the sum I/we am/are entitled to claim in the term of the policy. I/We also declare that the whole of the statement made by me/us in this form of claim are in any respect  true.
Witness my/our hand this day of
Witness Claimant’s signature  Occupation

Statement of the insurances in force upon the property above described
N  in the  Insurance Co., by policy No.
N  in the  Insurance Co., by policy No.

Discovery of loss: The insured must promptly take all practicable steps for tracing and recovering the lost/stolen money/stamps.Notification of Police: The police authorities must be notified of the loss without delay.
Accuracy of Statement: It is a condition of the policy that it shall be void if any claim be fraudulent or intentionally exaggerated or if any false declaration be made in support of it. It is therefore important that care should be exercised in filling the annexed statement.

QUESTIONS TO BE ANSWERED BY CLAIMANT
On what date and at what time was the loss discovered and by whom?
date time
Give date the Police were advised and name of Police station
DATE NAME OF POLICE

What other steps has been taken to discover the guilty person or persons, and to recover the money/stamps lost?

     
What is the amount of loss and of what did it consist?
Give the name and address of the employee in charge of the money/stamps
NAME
ADDRESS
In what capacity is he/she employed and how long has been in service
what capacity how long
Has he/she been concerned in any previous loss?
yes no
Do you have any reasons to doubt his/her integrity?
yes no
Have you ever sustained any previous loss coming within the scope of the policy?
yes no
If so, give details
NAME
DATE

<% End If %>


Untitled Document
 

 
 
Copyright © 2008 - 2012 Law Union & Rock Insurance Plc . All rights reserved. Staff Mail Access Site Credit