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Combined Fire & Theft Claim Form


Please complete all questions as fully as possible
Policy Number
Insured’s Name Email
Telephone no Address
Complete Address of destroyed property Date and Time of Fire
Full particulars of the loss or damage
I/We also declare that I am/we are (owner, mortgagor etc.) of the said property, and that no other person has any interest in the same except as stated.
State name, address and phone number of any other interested party
Property Last seen by me
State insurer and policy number of consequential loss insurer
Mitigating factors taken to avoid further loss
Statement of Insurances.
Company Policy No Amount
Details of claim for propery destroyed or damaged..
DAMAGE TO BUILDINGS: A detailed estimate by a Builder or other competent person should be submitted in support of the amount claimed, making due allowance for age, depreciation etc.
DAMAGE TO CONTENTS: A detailed statement of the various articles claimed for should be written in here or attached to the form. The claim must be based on the actual value of the property at the time of the fire i.e. – without any inclusion of profit and after allowance has been made for depreciation, wear and tear, etc.
Description of the property Value At time of Fire Deduction For value Of salvage Amount Claimed