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NOTIFICATION OF LOSS OR DAMAGE FOR ELECTRONIC EQUIPMENT INSURANCE FORM

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	Surname *	Surname is required.
	First Name *	First Name is required.
	Middle Name
	Title	Please select an item.
	Full Postal / Contact Address
	Phone Number (s)
	GSM Number
	Fax Number(If available)
	E-mail Address *	Email is required.

	We can send alerts to you for renewal of your policy(ies). Please confirm how you would prefer to recieve your alert.

Policy No: Claim No:

The isuuing of this form is not to be taken as an admission of liability by the insures.

Name and address of insured.

Location of object

Leading insurer

Period

Last premium payment

When did the loss or damage occur	Time : Date :
When was notice first given to the insurer?	To whom? By whom?

Are there any witnesses?

If so, please give names. Professions and addresses

Name and address of surveyor.

What item was damaged?

Item No in specification of Policy Schedule

Sum insured

Name of the manufacturer, Type of machine

Year of manufacture,Serial number (Please give full detail as on manufacturer's plate.)

Description of damaged item ( capacity, rpm weight, etc)

Are the damaged items also insured with another company?(*)	Please select an item.
If so with which
Scope of cover

How did the damage occur and what was the probable cause

Where damage to EDP system is involved,please indicate a loss report drawn up by the maintenance firm or supplier

In the event of damage to tubes or valves for X-ray Equipment
Age in months
Previous usage ( no of shots)
Hours of operation ( for depth therapy )

In the event of losses caused by burglary, theft, fire, traffic accidents
Which police station did you notify of the incident

Fire reference used by Public Prosecutor's Office

In the event of damage to radio equipment
Serial No of damaged equipment
License No(s) of the other vehicle(s) involved in the accident
File reference used by Public Prosecutor's Office

In the event of damage to traffic signals:
Name and full address of the person(s) who caused the accident
Licence No. of the car involved in the accident
Third party liability insure of the person(s) who caused the accident?

How will the damage items be repaired, by whom and where

Please indicate repair period

What are the estimated repair cost?

In the event of third parties having caused the loss, Who was to blame for the loss? (If possible, please give the full address of witnesses)

Who is authorized to recieve the idemnity?
Bank
Account No.

Date ddate

Please note that details of all items to be insured and their respective sums should be sent by fax or mail to our Corporate Office for further processing.

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