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FIDELITY GUARANTEE CLAIM FORM

For Corporate Organisation Click Here.

	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:

Date of Payment of last Premium

Name of Defaulter

Present Address*

Occupation at the date of the default

Date of Discovery of the default

Name of next of Kin

Date Defaulter was Employed

For how long and in what manner, has the default been carried on and concealed?

What lead to its discovery?

What is the amount of the default as at present ascertained?

Has there been any previous irregularity in the Defaulters' accounts? If so, state when and give particulars

When last was the account/stock audited?

Has he, so far as you know, any property, furniture or other effects?

Is there any salary, commission or other remuneration or allowance due to him?

Do you hold any other security in addition to this guarantee?/

Has the Defaulter been discharged from your service? If so, on what date?

Has a proposal for settlement been put forward by the defaulter?

Date 30-07-2010

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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