Property Loss Damage Claim Form - Step 1

Before starting to complete this form, please make sure you have the following at hand:

1. Insured

* Place where Loss / Damage occurred:
* Were the premises occupied?
If YES, by whom:
If NO, when were the premises last occupied:
Purpose of occupation and what was the purpose of occupation on this date:
* Date of Loss:

* Describe fully how the Loss / Damage occurred stating how (if applicable) entry was gained to premises:

If Loss / Damage was caused by another party give Name and Address:

* Have you previously suffered Loss / Damage?
If YES, give details:

If insured, provide name of insurer:

* Were your items either lost, stolen or misplaced?
Name of police station where accident was reported:
SAPS case reference No.:
Date Reported:

* Does any other party have an interest in the insured property, e.g. Credit Agreement
If YES, give name and interest:

* Is there any other insurance covering this Loss / Damage:
If YES, give name of Insurer:

Estimated total value of all the property insured under the policy:

When last valued:

You may select, for added security, payment of any amount due to you directly into a bank account. Please specify the name of the bank, branch, name of account and account number.
Name of Bank:		Branch:
Name of Account:		Account No.: