Property Loss/ Damage Claims Form Jan 18, 2019by Darryl Bome Property Loss/ Damage Claims Form Share Policy NumberField is required!Field is required!SECTION 1: INSURED<p>SECTION 1: INSURED</p>Name and SurnameField is required!Field is required!AddressField is required!Field is required!Email AddressField is required!Field is required!Business DescriptionField is required!Field is required!OccupationField is required!Field is required!ContactField is required!Field is required!SECTION 2: LOSS/DAMAGE INCIDENT<p>SECTION 2: LOSS/DAMAGE INCIDENT</p>Date of damage/ lossField is required!Field is required!Date of damage/ loss discoveryField is required!Field is required!Place where loss/ damage occurredField is required!Field is required!Were the premises occupied?<p>Were the premises occupied?YesNoField is required!Field is required!If yes, by whom, why?Field is required!Field is required!If no, last date of occupationField is required!Field is required!SECTION 3: CAUSE OF LOSS/DAMAGE<p>SECTION 3: CAUSE OF LOSS/DAMAGE</p>Outline the nature of how the loss/damage occurredField is required!Field is required!If another party caused the loss/damage, provide the names and addressesField is required!Field is required!SECTION 4: PREVIOUS DAMAGE<p>SECTION 4: PREVIOUS DAMAGEHave you previously suffered loss/damage?<p>Have you previously suffered loss/damage?</p>- select a option -YesNo- select a option -Field is required!Field is required!If yes, give detailsField is required!Field is required!If insured, give details of previous insurer:Field is required!Field is required!SECTION 5: POLICE<p>SECTION 5: POLICE</p>Police reference numberField is required!Field is required!Police StationField is required!Field is required!Date reportedField is required!Field is required!SECTION 6: OTHER INTERESTS<p>SECTION 6: OTHER INTERESTS</p>Has any other party had an interest in the insured property? If so, give name and interest. e.g Hire Purchase AgreementField is required!Field is required!SECTION 7: OTHER INSURANCE<p>SECTION 7: OTHER INSURANCE</p>If the loss/damage was covered by any other insurance, please provide the name of the insurerField is required!Field is required!SECTION 8: VALUE<p>SECTION 8: VALUE</p>Estimated total value of of the property insured under the policyField is required!Field is required!Last valuation dateField is required!Field is required!SECTION 9: DECLARATION<p>SECTION 9: DECLARATION</p>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.<p>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. <br /> <br /> 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.</p>CapacityField is required!Field is required!Select a dateField is required!Field is required!SECTION 10: STATEMENT OF PROPERTY, STOLEN OR DAMAGED<p>SECTION 10: STATEMENT OF PROPERTY, STOLEN OR DAMAGED</p>Number:<p>Number:</p>Description of Property<p>Description of Property</p>Date Acquired:<p>Date Acquired:</p>Acquired from<p>Acquired from</p>Amount Claimed:<p>Amount Claimed:</p>Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Submit
