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Property Loss/ Damage Claims Form

Policy Number
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SECTION 1: INSURED

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Name and Surname
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Address
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Email Address
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Business Description
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Occupation
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Contact
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SECTION 2: LOSS/DAMAGE INCIDENT

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Date of damage/ loss
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Date of damage/ loss discovery
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Place where loss/ damage occurred
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Were the premises occupied?

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If yes, by whom, why?
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If no, last date of occupation
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SECTION 3: CAUSE OF LOSS/DAMAGE

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Outline the nature of how the loss/damage occurred
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If another party caused the loss/damage, provide the names and addresses
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SECTION 4: PREVIOUS DAMAGE

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Have you previously suffered loss/damage?

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  • - select a option -
  • Yes
  • No
- select a option -
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If yes, give details
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If insured, give details of previous insurer:
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SECTION 5: POLICE

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Police reference number
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Police Station
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Date reported
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SECTION 6: OTHER INTERESTS

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Has any other party had an interest in the insured property? If so, give name and interest. e.g Hire Purchase Agreement
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SECTION 7: OTHER INSURANCE

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If the loss/damage was covered by any other insurance, please provide the name of the insurer
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SECTION 8: VALUE

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Estimated total value of of the property insured under the policy
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Last valuation date
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SECTION 9: DECLARATION

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I/we hereby declare that I/we have suffered the loss of or damage to the property enumerated on the reserve hereof and that the said property was in my/ our possession immediately prior to the loss/damage incident that occurred in the circumstance described above. I/we hereby warrant that the item/s being claimed for has been reported as well as black-listed with the relevant cellular service provider/s.

I/we hereby acknowledge that it is a further condition precedent to liability of the company under this policy that Pogir Group may make an enquiry, where applicable, to the relevant Cellular Service Provider/s or their authorized representatives to obtain further information regarding date and time of the device/s or sim card last usage.

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Capacity
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Select a date
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SECTION 10: STATEMENT OF PROPERTY, STOLEN OR DAMAGED

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Number:

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Description of Property

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Date Acquired:

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Acquired from

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Amount Claimed:

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