011 879 7200 / 7250

St Andrews Office Park

39 Wordsworth Avenue, St Andrews.

Stay informed! Visit the SA Department of Health’s website for COVID-19 updates: sacoronavirus.co.za

011 879 7200 / 7250

St Andrews Office Park

39 Wordsworth Avenue, St Andrews.

Property Loss/ Damage Claims Form

SECTION 1: INSURED

SECTION 2: LOSS/DAMAGE INCIDENT

Were the premises occupied?

SECTION 3: CAUSE OF LOSS/DAMAGE

SECTION 4: PREVIOUS DAMAGE

Have you previously suffered loss/damage?

  • - select a option -
  • Yes
  • No

SECTION 5: POLICE

SECTION 6: OTHER INTERESTS

SECTION 7: OTHER INSURANCE

SECTION 8: VALUE

SECTION 9: DECLARATION

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.

SECTION 10: STATEMENT OF PROPERTY, STOLEN OR DAMAGED

Number:

Description of Property

Date Acquired:

Acquired from

Amount Claimed:

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