ABSA Brokers (Pty) Limited/Makelaars (Edms) Beperk

Reg No 1970/002732/07
Property Loss/Damage Claim Form/Eiendomsverlies-/Skade-eisvorm
538299 (AIB 12) Authorised Financial Services Provider/Gemagtigde Finansilediensteverskaffer ABSA (07/2006)
Insurer
Versekeraar
Broker
Makelaar
Policy number
Polisnommer
Name and occupation Naam en beroep
Address and
(day) telephone
Date and time of
loss/damage
When was loss/damage
discovered?
Place where loss/damage
occurred
Were premises occupied?
By whom?
If not occupied when last
occupied?
Purpose of occupation
Describe fully how the loss
or damage occurred
stating how (if applicable)
entry was gained to
premises
If loss/damage was
caused by another party
give name and address
Have you previously
suffered a loss/damage
If so, give details
If insured provide name of
insurer
Police ref no and station
and date reported
Has any other party an
interest in the insured
property, eg Credit
Agreement
If so, give name and
interest
Is there any other
insurance covering this
loss/damage policy?
If so, give name of insurer
Estimated total value of all
the property insured under
the policy
When last valued?
I/We solemnly declare that I/we have suffered loss of or damage to the property enumerated on the reverse hereof and that the said property was in
my/our possession immediately prior to the said loss/damage which occurred in the circumstances described above.
Ek/Ons verklaar dat ek/ons die verlies of skade aan die eiendom, wat agterop beskryf is, gely het en dat genoemde eiendom onmiddellik voor die
verlies/skade in my/ons besit was en dat die verlies/skade plaasgevind het as gevolg van die omstandighede hierbo uiteengesit.
Insureds signature Capacity Date
Versekerde se handtekening _________________________________ Hoedanigheid ___________________________ Datum __________________________
Adres en
(dag) telefoon
Datum en tyd van
verlies/skade
Wanneer is verlies/skade
ontdek?
Plek waar verlies/skade
plaasgevind het
Was perseel bewoon?
Deur wie?
Indien onbewoon wanneer
is dit laas bewoon?
Vir watter doel is die
perseel gebruik?
Beskryf volledig hoe die
verlies of skade
plaasgevind het en meld
(indien van toepassing)
wyse waarop toegang tot
die perseel verkry is
Indien verlies/skade deur
n ander persoon
veroorsaak is meld naam
en adres
Het u vantevore verlies of
skade gely?
Indien wel, verskaf
besonderhede
Indien verseker verskaf
naam van versekeraar
Polisie verw-no en stasie
en datum gerapporteer
Het enige ander persoon
n belang in die versekerde
eiendom, bv
Kredietooreenkoms
Indien wel, meld naam en
belang
Is daar enige ander
versekering wat hierdie
verlies/skade dek?
Indien wel, meld naam
van versekeraar
Beraamde totale waarde
van al die eiendom
verseker onder die polis
Wanneer laas is dit
gewaardeer?
Branch
Tak
Branch
Tak
Absa
Claim number
Eisnommer
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