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MONEY 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.

Mobile Tel. No. *
Tel. No.
E-mail Address *

I / We of

Being insured under Policy No do hereby declare that at or about o'clock on
the day of 20 a loss occured occasioned, to the best of my/our knowledge and belief, in

the following manner

And I/We further declare that the money / stamps overleaf, belonging to me / us and insured under the said Policy, was / were lost / stolen and represent(s) the sum I / We am are entitled to claim in the terms of the policy.

I/We also declare that the whole of the statement made by me in this form of claim are in every respect true.

Witnessed by my/our hand this day of of 20

Claimant Occupation
Witness Full name
Witness Occupation

Statement of the insuranes in force upon the property above described

N in the Insurance Co., by Policy No

Discovery of Loss: The insured must promptly take all practicable stpes for tracing and recovering of the lost / stolen money / stamps

Notification of Policy: The Police Authorities must be notified of the loss without delay.

Accuracy of Statement: It is a condition of the Policy that it shall be void if any claim be fraudulent or intentionally exaggerated or if any false statement or declaration be made in support of it. It is therefore important that care should be exercised in filling up the annexed statement.

QUESTIONS TO BE ANSWERED BY CLAIMANT

On what date at what hour was the loss discovered and by whom?

Give date the Police were advised and name of the Police Station

Date
Name of Station

What other steps have been taken to discover the guilty person or personsk and to recover the money/stamps lost?

What is the amount of the loss and of what didi it consist?

5a)	Give name and address of the employee in charge of the money / stamps?
5b)	In what capacity is he employed by you ?
5c)	How long has he been in your service?
5d)	Is he still in your service?
5e)	State the salary, commision or other renumeration paid to him

6a)	How much was in the employee's charge at the commencement of the journey?
6b)	What disbursements were made by him during the journey?
6c)	Have you any reason to doubt the integrity of the employee?

Have you ever sustained a previous loss coming within the scope of this policy?

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

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