Catastrophe Claim Form

Policy Number
Claims number:
Insured Name:
FirstLast
TRN
Insured Mailing Address
Phone number (work):
Phone number (home):
Mobile number:
Name, Address & Telephone No. of contact person (if different from Insured):
Date of loss:
Time of loss:
: HH
MM
Email Address:
Type of loss:
Address of loss:
Give specific direction of Loss location:
Nature of Occurrences:
Description of Loss/ Damage:
For what purpose was the premise occupied at the date of the Loss?
If there is more than one building, please describe damage to each building
Damage to/loss of contents must be detailed here:
Estimated cost of repairs (if known): $
PLEASE SUBMIT WRITTEN ESTIMATE AS SOON AS POSSIBLE
Is the Insured the sole owner of the property ?
- Yes
- No
If not, please state full particulars of any other interested party e.g. Mortgagee
Give full particulars of any other existing Insurance on the Property whether effected by the Insured or by any other person
Insurance Company:
Name of Insured:
Sum Insured : $
If there is no other Insurance, write ‘NONE’
LIST OF PROPERTY DAMAGED OR DESTROYED
When a Building is the subject of the Claim, a detailed Estimate must accompany this Form.
No.
Description of the Property destroyed or damaged. Particulars to be given in detail.
Amount Insured
Value immediately previous to the loss/damage
Value of Salvage
Amount Claimed
Attach Files; such as invoices, estimates, receipts (maximum 5 files, maximum size 50MB)
Drop files here or
Attach Photos (maximum 5 photos, maximum size 50MB)
Drop files here or
I/We do hereby declare that the above is a full true and accurate statement and that I/we have withheld no information material to the claim, and I/we further declare that the articles mentioned in the above table(s) being my/our property and insured under the above named Policy or Policies were destroyed or damaged by the aforesaid peril.*
- Agree
Date