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"FIRE LOSS" FORM

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

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Fire Loss No Please refer to the Instructions when preparing your Claim Branch or Agency CLAIM UNDER Policy No(s)

I/We now residing at being the Insured under the above-mentioned Policy , do hereby declare that, on or about o'clock , on the day of 20 , a Fire occured in the
1. of the
2. situated at caused, to the best of my/our belief by
3. I/We further declare that the property mentioned herein was insured under items(s) No(s) of the aforesaid Policy , and was destroyed or damaged by the said Fire, that prior thereto it was of the value stated on page 2 under the heading "Value immediately before the Fire" and that in consequence of the Fire the said property sustained damage as shown under the heading "Amount of damage sustained". I/We furthermore declare that I am/we are the
4. of the said property and that no other person has any interest in the same except as
5. and that the following is a full and complete statement of all the Insurances effected upon the said property whether with the Leadway Assurance Company Limited, or otherwise.

Note:
1. Here State the room or place where the fire originated.
2. Here insert Description of premises e.g Dwelling, Shop, Cotton Mill.
3. The cause of the fire should be stated as explicitly as possible.
4. The Insured should here state the nature of his or her interest in the property, e.g Owner, Mortgagee, Less or Hire purchaser, etc.
5. Here state the nature of any other interest in the property. If there is any mortgage on the property the fact must be stated.

STATEMENT OF INSURANCES

POLICY NO.	COMPANY	AMOUNT

I/We therefore claim from the Leadway Assurance Company Limited.

the sum of signed this day

NB: The forwarding of this form for completion does not constitute an admission of liability

VALUE OF THE WHOLE OF THE INSURED PROPERTY

DESCRIPTION	Number or Quantity	Value immediately before Fire	Value of Salvage	Amount of Damage Sustained

DETAILS OF PROPERTY DESTROYED OR DAMAGED
N.B: When the policy consists of more thatn one item, only the item or items in respoect of which a claim is made need be detailed below.

Item No.	Description	Value immediately before the Fire (N)
1
2
3
4
5
6
7
8
9
10
11
12

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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