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Burglary Claim Form


Please complete all questions as fully as possible
Policy Number
Insured’s Name Email
Telephone no Address
   Address of premises where theft occurred.
State the exact location in the premises From where the articles stolen were removed.
Property Last seen by you
Date and time of theft. Date and time loss was discovered.
Brief description of incident
Date and time the police were advised of loss. Name of police station? (Attach report)
Was anyone at the premises during the burglary? If yes, provide details
How many days have the premises been unoccupied During the past Twelve months Is the premises guarded by a watchman?
If yes provide details of names, telephone number and Whereabouts during burglary. State name of security agent (attach contract of agreement)
Were all means of access of the premises properly secured at the time of the theft? Do you suspect any person? if yes provide details
What was the total value of the contents of your premises at the time of the theft?               Are there any other Insurances against theft upon the same property? if yes provide details
State where the stock books and records were located at the time of the theft.              Give details of records of previous loss in the premises or any other premises on similar goods.
Instructions Regarding Claims
1. The statement of claim should be completed and forwarded to the company immediately.
2. The police must be advised of the loss immediately.
3. The insured must at once take every practicable step that may lead to the recovery of the stolen property and any expenses that may have been incurred in processing the claim. Special notices:-
By the conditions the policy is rendered void if any claim be fraudulent or intentionally exaggerated, or if false statement or declaration be made in support of it. It is therefore important that this claim form should be completed with great care.
if any of the insured property that is subject of this claim is recovered either before or after indemnity has been provided under the within named policy the company must be notified immediately.
Details of claim
No of Articles Full Description When Brought Name & Address of Seller Price Paid Amount Claimed