LOSS REPORT FORM

EXPENDITURE FINANCIAL CONTROL DIVISION

LOSS REPORT POLICY FPP:140 TELEKOM NETWORKS MALAWI LIMITED

INFORMATION OF THE PERSON INCURRING OR REPORTING THE LOSS INSURANCE

NAME CONTROL ID

POSITION DATE REPORTED

DIVISION

LOCATION

REGION

DATE

LOSS INFORMATION

DESCRIPTION OF ASSET LOST VEHICLE ACCIDENT

ESTIMATED VALUE OF LOSS REGISTRATION NUMBER

BOOK VALUE OF THE ASSET NAME OF DRIVER

REGION/DIVISION

DESCRIPTION OF THE ACCIDENT/LOSS

OUTLINE BRIEFLY THE DETAILS OF THE INCIDENT OR OCCURRENCE (Attach detailed report)

CRIMINAL INCIDENT OR VEHICLE ACCIDENT

OUTLINE BRIEFLY THE DETAILS AS REPORTED TO POLICE (Attach police report) POLICE CASE NUMBER

POLICE STATION

POLICE OFFICER

EXPENDITURE FINANCIAL CONTROL

PERSON REPORTING THE LOSS FINANCIAL MANAGER, CAPEX HOD- EFCD

NAME NAME NAME

DATE DATE DATE

SIGNATURE SIGNATURE SIGNATURE

APPROVAL

CHIEF OFFICER OR MANAGING

SECURITY MANAGER HEAD OF REGION OR DIVISION EXECUTIVE CHIEF FINANCE OFFICER CHIEF EXECUTIVE OFFICER

DATE Peter Kadzitche Michiel Buitelaar

NAME

SIGNATURE

COMMENT