Property Loss/ Damage claim form/ Eiendomsverlies-/ skade-eisvorm

Insurer Branch
Versekeraar Tak
Broker Branch
Makelaar Tak
Policy number Claim number
Polisnommer Eisnommer
INSURED

Name and Occupation Naam en beroep

VERSE-
KERDE
Address and (day)
Adres en (dag) telefoon
telephone number
OCCURANCE

Date and time of Datum en tyd van verlies/

VOORVAL
DAMAGE

VERLIES/
SKADE
LOSS/

loss/damage skade
When was loss/damage Wanneer is verlies/ skade
discovered? ontdek?
Place where loss/ damage Plek waar verlies/ skade

VERLIES/SKADE PLEK
occurred plaasgevind het
LOSS/DAMAGE

Were premises occupied? Was perseel bewoon?

PLACE

By whom? Deur wie?

If not occupied when last Indien onbewoon wanneer is
occupied? dit laas bewoon?
Vir watter doel is die perseel
Purpose of occupation
gebruik?
Beskryf volledig hoe die
CAUSEOFLOSS/ DAMAGE

Describe fully how the loss

verlies of skade plaasgevind
or damage occurred

VERLIES/ SKADE
OORSAAKVAN
het en meld (indien van
stating how (if applicable)
toepassing) wyse waarop
entry was gained to
toegang tot die perseel verkry
premises
is
If loss / damage was Indien verlies / skade deur n
caused by another party ander persoon veroorsaak is
give name and address meld naam en adres
Have you previously Het u vantevore verlies of
PREVIOUSLOSS/

VORIGEVERLIES/
suffered a loss/ damage? skade gely?
DAMAGE

SKADE
Indien wel, verskaf
If so, give details
besonderhede
If insured provide name of Indien verseker verskaf naam
insurer van versekeraar

POLISIE
POLICE

Police ref no. and station Polisie verw- no en stasie en

and date reported datum gerapporteer

Has any other party an Het enige ander persoon n

ANDERBELANG
interest in the insured belang in die versekerde
INTEREST
OTHER

property, eg. Credit eiendom, bv

Agreement? Kredietooreenkoms?
If so, give name and Indien wel, meld naam en
interest belang
Is there any other Is daar enige ander
VERSEKERING
INSURANCE

insurance covering this versekering wat hierdie

ANDER
OTHER

loss / damage policy? verlies / skade dek?

Indien wel, meld naam van
If so, give name of insurer
versekeraar
Estimated total value of all Beraamde totale waarde van
WAARDE

the property insured under al die eiendom verseker

VALUE

the policy onder die polis

Wanneer laas is dit
When last valued?
gewaardeer?

I/we solemnly declare that I/we have suffered loss of or damage to the property enumerated on the following page, and that the said
property was in my/our possession immediately prior to the said loss/ damage which occurred in the circumstances described above
DECLARATION

VERKLARING

Ek/Ons verklaar dat ek/ons die verlies of skade aan die eiendom, wat op die volgende bladsy beskryf is, gely het en dat genoemde
eiendom onmiddellik voor die verlies/skade in my/ons besit was en dat die verlies/skade plaasgevind het as gevolg van die
omstandighede hierbo uiteengesit.

Insureds signature Capacity Date

Versekerde se handtekening _______________________ Hoedanigheid _______________________ Datum ______________

Authorised Financial Services Provider A Member of the Group

STATEMENT OF PROPERTY LOSS, STOLEN OR DAMAGED OPGAWE VAN EIENDOM WAT VERLOOR, GESTEEL OF BESKADIG IS
NB: Claims in respect of damage to buildings must be accompanied by a builders estimate LW: Eise ten opsigte van skade aan geboue moet van n raming van n bouer vergesel wees

Number Description of property Date acquired From whom purchased or acquired Value Amount claimed
Getal Beskrywing van eiendom Datum verkry Van wie gekoop of verkry Waarde Bedrag geis