PROPERTY CLAIM FORM FOR EVERY CLAIM COMPLETE SECTIONS A, B, & C. IF YOUR CLAIM FOR LOSS OR DAMAGE TO CONTENTS COMPLETE SECTION D. FOR BUILDING DAMAGE COMPLETE SECTION E. MONEY & CREDIT CARD LOSSES WILL REQUIRE COMPLETION OF SECTIONS F &G RESPECTIVELY. IN EVERY CASE REMEMBER TO SIGN AND DATE THE DECLARATION AT THE END OF THE FORM OTHERWISE WE CANNOT PROCEED. MAKING A CLAIM We appreciate how upsetting events which give rise to a claim can be, so we designed this form to ease you through the information we need to assess your claim quickly and accurately, and point out what additional information we require. Whilst we recommend that you complete this form thoroughly before you return it, if you feel that circumstances may delay its completion for too long, please contact us and we will advise you on how best to proceed. A. POLICYHOLDERS DETAILS Name: Address : Telephone: Telephone (Work): Telephone (Cell): Employer : Occupation: (Include part time work) B. POLICY DETAILS Is this the first notification of this loss? YesNo Policy Number: Renewal Date: Sums Insured: Buildings - Contents - Other (please specify) - C.GENERAL QUESTIONS 10. EXACTLY WHERE DID THE LOSS OR DAMAGE OCCUR? Please give full details. (At the above address is not usually sufficient to enable us to deal with your claim without further enquiry) 11. WHEN DID THE LOSS OR DAMAGE OCCUR? Date : Time : AMPM 12. GIVE FULL DETAILS OR CIRCUMSTANCES OF LOSS OR DAMAGE. (In case of loss it is often helpful to describe when you became aware of the loss and when the item was last seen. If theft from your home is involved describe fully how entry was gained) 13. HAVE THE POLICE BEEN INFORMED OF THE LOSS OR DAMAGE? (It is a Policy condition to tell the police about any theft, malicious damage, vandalism or loss of money, credit cards, jewellery or other valuable. Many items are ‘handed in’ and an enquiry is worthwhile). YESNO 14. ARE YOU THE SOLE OWNER OF THE PROPERTY OR BUILDINGS INVOLVED IN THE CLAIM? If No, give details of any co-owner. If you are a Tenant, give landlord’s name and address. YESNO CO-OWNER: LANDLORD’S NAME: LANDLORD’S ADDRESS: 15. DO YOU HOLD ANY OTHER INSURANCE COVERING THE PROPERTY OR BUILDING INVOLVED IN THIS CLAIM? If Yes, give full details with name and address of the Company and Policy Number. YESNO COMPANY: ADDRESS:: POLICY #: 16. WERE THE PREMISES OCCUPIED AT THE TIME OF THE LOSS OR DAMAGE? If Yes, by whom? If No, give the date and time when last occupied. YESNO NAME: DATE: TIME: AMPM 17. HAVE YOU EVER SUSTAINED ANY LOSS WHETHER INSURED OR NOT OF A SIMILAR NATURE? If Yes, give details. YESNO D. CONTENTS CLAIM 18. THE PANEL BELOW CAN BE USED TO DESCRIBE ANY ITEM EXCEPT BUILDINGS (SEE SECTION E), MONEY OR CREDIT CARD LOSSES (SEE SECTIONS F & G). AN ESTIMATE FOR REPAIR OR SPECIALIST’S CONFIRMATION THAT THE ITEM IS BEYOND REPAIR (IF APPROPRIATE) WILL BE REQUIRED AND IT SHOULD BE ATTACHED TO THIS FORM. OTHERWISE DESCRIBE THE ITEM FULLY IN THE APPROPRIATE COLUMN AND THE CURRENT PRICE OF A COMPARABLE ARTICLE. YOU SHOULD ENCLOSE ANY PURCHASE RECEIPTS THAT YOU HAVE FOR THE ARTICLE(S) IN QUESTION. DESCRIPTION DATE OF PURCHASE OR ACQUISITION COST WHEN PURCHASED OR ACQUIRED AMOUNT CLAIMED E. BUILDINGS CLAIM IF THE CLAIM IS FOR BUILDING DAMAGE YOU SHOULD TRY TO OBTAIN MORE THAN ONE ESTIMATE FOR THE WORK. THERE IS NO OBJECTION TO YOU GIVING YOUR OWN INSTRUCTIONS TO REPAIRS WHERE WORK IS REQUIRED URGENTLY TO MAKE THE PREMISES WEATHERPROOF OR SECURE, FOLLOWING DAMAGE CAUSED, FOR EXAMPLE, BY STORM. (IF SO, PLEASE NOTIFY US BY TELEPHONE AT THE EARLIEST OPPORTUNITY). WE WILL SOMETIMES INSTRUCT INDEPENDENT LOSS ADJUSTERS TO ASSIST US IN DEALING WITH THE CLAIM. WE WILL LET YOU KNOW WHEN WE DO SO. THE LOSS ADJUSTER WILL CONTACT YOU DIRECTLY TO ARRANGE A MUTUALLY CONVENIENT APPOINTMENT AND WILL THEN CALL TO INSPECT THE DAMAGE AND SORT OUT THE DETAILS OF THE CLAIM. THE ADJUSTER ACTS INDEPENDENTLY AND ONCE THE CLAIM HAS BEEN AGREED WITH YOU A REPORT WILL BE SUBMITTED TO US. ALTERNATIVELY, ON OCCASION WE MAY INSTRUCT A REPRESENTATIVE FROM OUR OFFICE TO CONTACT YOU. F.MONEY LOSSES 20. WHO DID THE MONEY BELONG TO? 21. WERE ARRANGEMENTS MADE TO ‘STOP’ CHEQUES OR POSTAL/MONEY ORDERS? YESNO 22. GIVE DETAILS OF ALL MONEY, CHEQUES, ETC., LOST, STOLEN OR DAMAGED. 23. TOTAL AMOUNT G. CREDIT CARD USED BY UNAUTHORIZED PERSONS 24. IN WHAT NAME WERE THE CARDS ISSUED? (IF NOT THE INSURED, GIVE THE NAME AND ADDRESS OF THE HOLDER) 25. WAS THE LOSS REPORTED TO THE ISSUING COMPANY WITHIN 24 HOURS OF THE LOSS OR THEFT BEING DISCOVERED? IF NO, EXPLAIN WHY. YESNO 26. GIVE THE NAME AND ADDRESS OF THE ISSUING COMPANY FOR EACH CARD AND STATE THE CARD NUMBER AND THE AMOUNT BEING CLAIMED. NAME OF ISSUING COMPANY ADDRESS OF ISSUING COMPANY CREDIT CARD NUMBER AMOUNT BEING CLAIMED 27. IS LOSS OF THE CARDS INSURED ELSEWHERE? IF YES, GIVE DETAILS. YESNO I/WE HEREBY DECLARE THAT THE INFORMATION GIVEN ON THIS FORM IS TRUE TO THE BEST OF MY/OUR KNOWLEDGE.
New ProvidenceGrand Bahama Abaco Eleuthera Exuma