General claims form

Declaration

I/We warrant the truth of the answers to the questions below and I/we declare that no information has been withheld and that the amount claimed represents my/our loss arising from the stated occurrence. By submitting this claim I declare herewith that I am the Insured in terms of this policy.

[* Indicates required fields]

Policy number:

Insured's lastname and initials, or company name:*

Insured's e-mail address:

Phone number - Home:

Phone number - Work:

Cellphone number:

Insured's Identity Number:

Description of loss or damage:

Date:*

Time:

Type of claim:

Describe fully how the loss or damage occurred:

At what location (address) did the loss occur?:

Address line 1:

Address line 2:

Address line 3:

City:

Province:

Postal code:

The description and value of each item claimed:*

Police Report Details

Was the loss or damage reported to the police?

Date:

Please state where you reported the event:

Police reference Number:

I certify that the above information is correct.*

(Mark box)

I certify that I agree to the Declaration.*

(Mark box)

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