All Risk Claim Form

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CLAIM FORM

FOR ALL RISKS, FIRE, MONEY, HOUSEHOLDERS, HOMEOWNERS, BURGLARY, COMBINED, SPECIAL PERILS

VERSEKERAAR
INSURER

POLISNR.
POLICY NO.

SERTIFIKAATNR.
CERTIFICATE NO.

EISNR.
CLAIM NO.

MAG-, PENSIOEN-, SALARIS OF PERSONEELID NR.
FORCE, PENSION, SALARY OR PERSONNEL NO.

NAAM VAN GROEP SKEMA
NAME OF GROUP SCHEME

01 DIE VERSEKERDE / THE INSURED

NAAM
NAME

IDENTITEITS NR.
IDENTITY NO.

ADRES
ADDRESS

POSKODE
POSTAL CODE

BESIGHEID
BUSINESS

HUIS
HOME

TELEFOON NR.
TELEPHONE NO.

BEROEP OF BESIGHEID
OCCUPATION OR BUSINESS

02 ADRES WAAR DIE VERLIES OF SKADE PLAASGEVIND HET
ADDRESS AT WHICH THE LOSS OR DAMAGE OCCURRED

03 WANNEER HET DIE VERLIES OF SKADE PLAASGEVIND?
WHEN DID THE LOSS OR DAMAGE OCCURRED

DATUM
DATE

TYD
TIME

04 BESKRYF VOLLEDIG HOE DIE VERLIES OF SKADE PLAASGEVIND HET
DESCRIBE FULLY HOW THE LOSS OR DAMAGE OCCURRED

05 HET U AL VANTEVORE SKADE GELY?
HAVE YOU PREVIOUSLY SUFFERED A LOSS?

YES

VOLLE BESKRYWING VAN VORIGE EISE/VERLIESE
FULL DESCRIPTION OF PREVIOUS CLAIMS/LOSSES

06 WAS DIE PERSEEL TEN TYDE VAN DIE VERLIES OF SKADE BEWOON?
WERE THE PREMISES OCCUPIED AT THE TIME OF THE LOSS OR DAMAGE?

YES

INDIEN NIE, WANNEER WAS DIT LAAS BEWOON?
IF NOT, WHEN WAS IT LAST OCCUPIED?

07 VIR WATTER DOEL WAS DIE PERSEEL TEN TYDE VAN DIE VERLIES OF SKADE IN GEBRUIK?
HOW WERE THE PREMISES OCCUPIED AT THE TIME OF THE LOSS OR DAMAGE?

08 IS DIE VERLIES OF SKADE BY DIE POLISIE AANGEMELD?
WAS THE LOSS OR DAMAGE REPORTED TO THE POLICE?

YES

INDIEN NIE, HOEKOM NIE?
IF NOT, WHY NOT?

INDIEN WEL, WANNEER EN WAAR?
IF SO, WHEN AND WHERE?

S.A. POLISIE VERWYSINGSNR.
S.A. POLICE REFERENCE NO.

09 IS U DIE ALLEEN-EIENAAR VAN DIE EIEDOM VAT VERLOOR OF BESKADIG IS?
ARE YOU THE SOLE OWNER OF THE LOST OR DAMAGED PROPERTY?

YES

INDIEN NIE, VERSKAF VOLLE BESONDERHEDE VAN ANDER BELANHEBBENDES
IF NOT, GIVE FULL PARTOCULARS OF THE OTHER PARTIES CONCERNED

10 IS DAAR 'N VERBAND OP DIE EIENDOM?
IS THERE A BOND ON THE PROPERTY?

YES

NAAM DIE VERBANDHOUER
NAME OF THE BONDHOLDER

11 WAT IS DIE WAARDE VAN DIE HELE INHOUD VAN DIE PERSEEL TEN TYDE VAN DIE VERLIES OF SKADE?
WHAT IS YOUR ESTIMATE OF THE VALUE OF THE ENTIRE CONTENTS AT THE TIME OF THE LOSS OR DAMAGE?

12 WAT IS U RAMING VAN DIE WAARDE VAN DIE GEBOU(E) TEN DYDE VAN DIE VERLIES OF SKADE?
WHAT IS YOUR ESTIMATE OF THE VALUE OF THE BUILDING(S) AT THE TIME OF THE LOSS OR DAMAGE?

13 HET DIE GEBOU(E) 'N RIETDAK?
HAS THE BUILDING(S) A THATCH ROOF?

YES

14 IS DIE EIENDOM WAT VERLOOR OF BESKADIG IS KRAGTENS ENIGE ANDER POLIS VERANDER?
IS THE LOST OR DAMAGED PROPERTY INSURED UNDER ANY OTHER POLICY?

EK/ONS WAARBORG DIE WAARHEID VAN DIE ANTWOORDE OP DIE BOGEMELDE VRAE EN EK/ONS VERKLAAR DAT GEEN INLIGTING
VERSWYG IS NIE EN DAT DIE GENOEMDE GEEIS MY/ONS VERLIES WAT UIT DIE GENOENDE GEBEURE ONTSTAAN HET VERTEERNWOORDIG

I/WE WARRENT THE TRUTH OF THE ANSWERS TO THE ABOVE QUESTIONS AND I/WE DECLARE THAT NO INFORMATION HAS BEEN
WITHHELD AND THAT THE AMOUNT CLAIMED REPRESENTSMY/OUR LOSS ARISING FROM THE ABOVE STATED OCCURRENCE.

AANVAAR JY HIERDIE AS KORREK?
DO YOU ACCEPT THIS TO BE TRUE?

I DO NOT ACCEPT

I ACCEPT

DIE UITREIKING VAN HIERDIE VORM IS NIE 'N ERKENING VAN AANSPREEKLIKHEID NIE.
THE ISSUE OF THIS FORM IS NOT AN ADMISSION OF LIABILITY

OPGAWE VAN EIENDOM VAT VERLOOR, GESTEEL OF BESKADIG IS
STATEMENT OF PROPERTY LOST, STOLEN OR DAMAGED

EISE TEN OPSIGTE VAN SKADE AAN GEBOUE MOET VAN 'N RAMING VAN 'N BOUER VERGESEL WEES
CLAIMS IN RESPECT OF DAMAGE TO BUILDINGS MUST BE ACCOMPANIED BY A BUILDERS ESTIMATE

GETAL
NUMBER

OMSKRYWING VAN EIENDOM
DISCRIPTION OF PROPERTY

DATUM VERKEY
DATE ACQUIRED

VAN WIE GEKOOP OF VERKRY
FROM WHOM PURCHASED OR ACQUIRED

AFTRKKING VIR SLYTASIE
OR WAARDEVERMINDERING
OF WAAARDE VAN WRAKGOED

DEDCUTION FOR WEAR AND
TEAR OR DEPRECIATION
OR VALUE OF SALVAGE

BEDAR GEEIS
AMOUNT CLAIMED

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INDIEN WEL, VERSTREK BESONDERHEDE
IF SO, GIVE FULL PARTICULARS

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