Welcome to Leadway Group : Commercial Insurance

Untitled Document

	Bancassurance Login
Username: Password:

Untitled Document

Home » Commercial Insurance » Quotes and Forms » Forms

BURGLARY CLAIM FORM

PLEASE NOTE: An agent who completes a Proposal Form does so as an agent of the proposer.

It is essential that every question with * be answered fully for proper processing of the form.

POLICY NO.

(a)

Full Name of Insured *

Your full name is required.

(b)

Full Postal Address *
(to which all correspondence would be sent)

Postal address is required.

(c)

Mobile Tel. No. *

Mobile No is required.

(d)

Tel. No.

Tel No. is required.

(e)

E-mail Address *

Email is required.


1	Address of premises at which theft was committed *	Address is required.
2	State date and time of theft
3	How was entry effected?
4	Do you suspect any person?
5	Date and hour loss was discovered.
6	Date the police were advised of loss
6a	At what station.
7a	Was there anyone at the premises at the time
7b	Give name and address
8	How many days have the premises been unoccupied during the past twelve months
9a	If a night watchman is employed, where was he at the time of the theft?
9b	State name of security agent (Enclose with this Contract at Agreement)
10	State the exact location in the premises from which the articles stolen were removed.
11	Were all means of access to the premises properly secured at the time the theft?
12	What was the total value of the contents of your premises at the time of the theft?
13	Amount of Fire Insurance on the premises and the name of the Fire Insurance Co.
14	Are there any other Insurances against theft upon the same property? If so give details.
15	If Taxi/Bus How many passengers
16	Give Details of records of previous loss in the premises or any other premises on similar goods

Instruction Regarding Claims

1. The statement of claim should be completed and forwarded to the Company immediately.
2. The Police must be advised of the loss immediately.
3. The Insured must at once take every practicable step that may lead the discovery and punishment of the guilty party or parties, also for tracing and recovery of the property stolen, and should communicate to the Company any suspicions he may have as to the person(s) responsible.
4. Private residence. The following particulars are necessary:-
List of articles stolen, Cost price of each when bought, supported by Reciepts
Value at time of theft after allowing for depreciation.
5. Business Premises. The following particulars are necessary:-
List of articles stolen.

Net wholesale cost price of each article; when and where bought and manufacturer's name
Value of articles at time of theft.

Special Notice:-
By the conditions the Policy is rendered void if any claim be fraudulent or intentionally exaggerated, or if false statement or declaration be made in support of it. It is therefore important that his claim form should be completed with great care.

STATEMENT OF CLAIM
IF ANY OF THIS PROPERTY IS NOT OWNED BY YOU PLEASE GIVE PARTICULARS

No. of Articles	Full description	When bought	Name and Address of seller	Price paid	Amt Claimed

IF ANY OF THE INSURED PROPERTY THE SUBJECT OF THIS CLAIM IS RECOVERED EITHER BEFORE OR AFTER INDEMNITY HAS BEEN PROVIDED UNDER THE WITHIN NAME POLICY THE COMPANY MUST BE NOTIFIED IMMEDIATELY

I/We hereby declare the within mentioned property belonging to me/us (or a member of my household permanently residing with me ) and insured byt hte said Policy was stolen in the circumstances described within and that in consequence of such theft a claim is hereby made for the sums severally stated within; and I/We

Further declare that no person except has any interest in the said property.

Witnessed this Day: 30-07-2010

I agree with all the terms and conditions. click here to read terms and conditions.

Follow this link to go back the page you were previously looking at.

Untitled Document