Notification of Physical Loss or Damage
(The issue of this form is not to be taken as an Admission of Liability)
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DETAILS OF INSURED

   
 

DETAILS OF OTHER INSURANCES

 
 
 
 
 

DETAILS OF LOSS

  

I/We hereby agree, affirm and declare that:

  • The statements/information given/stated by me/us in this claim form are true, correct and complete.
  • The details of all persons having an interest in the property in respect of which the claim is being made are provided as per the proposal form or by way of any endorsement in the policy. Furthermore, save and expect as provided or disclosed in this claim form, no claim made hereunder (or the same/similar claim) has been made or lodged with any other insurance company.
  • No materials information which is relevant to the processing of the claim or which in any manner has a bearing on the claim has been withheld or not disclosed.
  • If I/We have given/made any false or fraudulent statement/information, or suppressed or concealed or in many manner failed to disclosed material information, the policy shall be void and that I/We shall not be entitled to all/any right to recover there under in respect of any or all claims, past, present, future.
  • The receipt of this claim form/other supporting/related documents does not constitute an agreement by the Company of the claim and the company/reserve the right to process or reject or require further/additional information in respect of the claim.