QUESTIONNAIRE

GENERAL INFORMATION
Please fill in and complete the questionnaire below based on your best understanding and knowledge as regards the
incident :

1. Time, day and date of the incident :

……………………………………………………………………

2. Is there any witness at the time of incident ? Yes/ no

If Yes, please mention the person who witness the incident :
………………………………………………………………………………………………………
………………………………………………………………………………………………………

3. Where did the incident initially take

place? ................................................................................................................................................
.........

4. Suspected cause of loss :

…………………………………………………………………………………………………….

5. Please mention all kinds of property that were damaged/ affected, including the extent
of damage : (If the given space is not sufficient, please write down the damaged property on the separate
list)
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………

6. Have you taken any preventive action to avoid further losses ? Yes/ no
If yes, please specify :
………………………………………………………………………………………………………
………………………………………………………………………………………………………

7. What action that you were taking to mitigate the loss ?

Please specify :
………………………………………………………………………………………………………
………………………………………………………………………………………………………

8. Loss estimate :
…………………………………………………………………………………………….

9. Have you contacted any contractor/ authorized repairer/ vendor/ supplier to carry out
detailed examination on the damaged property and to find out the precise cause of loss ?
Yes/ no
If Yes, please mention the company’s name :
…………………………………………………..…………………………………………………
 10. Is there any other party who has financial interest in the damaged property ? Yes/ No
If Yes, please mention the name :
………………………………………………………………………..

11. Was the premises occupied and guarded at the time of incident ? Yes/ No
If Yes, please mention how many security guards were on duty at the time of loss:
……………………………………………………………………………………………..

Number of shifts per day : ………………………..

Total security personnel : …………………………

12. Have you reported this incident to the Police ? Yes/ No

If Yes, when ? ………………………………………………

13. Do you always maintain and check your electrical system regularly ? Please mention
when was the last maintenance taken ?...............................................................................

14. Did you notice any uncommon/ abnormal sounds, signs or marks right before the
incident ? Yes/ no
If yes, what did you do ?
………………………………………………………………………………………………………
………………………………………………………………………………………………………
……………….

15. Have you warned or given any advice to the third party regarding the potential loss
exposure that might happen? Yes/ No
If Yes, please specify :
……………………………………………………………………………………………………..

I/We hereby confirm that the above information which presented in this questionnaire is true
and shall be considered material. Should there be any false information, misrepresentation and
non disclosure found in this questionnaire, I/ We are aware of the consequences and shall be
legally responsible accordingly.

Jakarta,…………………….

Name :

Position :