BURGLARY CLAIM FORM

The issue of this form is not to be taken as an admission of liability by the Insurers. This claim form should be completed and returned within seven (7) days of its receipt by the INSURED. Fire & GA Claims Dept, Fax : 6225 9887
Name of Policyholder
Policy No
Contact Person
Email
Tel No
NRIC No
Address
Address of the premises at which the loss occurred
On what date and time were your premises broken into?
@ about
On what date and hour was the robbery discovered?
@ about
Robbery was discovered by
Which rooms were ruffled?
Describe means by which entry was obtained and state
what doors or windows were forced open?
Were the premises occupied at the time? If not, upon what date and at what time were they last occupied?
Any suspect? If so, state the name
Are you the sole owner of the property stolen/damaged?
Are there any other insurance against theft upon the same property?

Please specify:
What was the value of the total contents at your premises at the time of the loss?
Have you ever before sustained loss by fire, burglary, housebreaking or larceny?
If Yes, please provide history of previous claim/s made (include name, date, nature of loss & amount paid)
Please state the total amount claimed next page. Give a detailed list (with separate value of each article or item) of the property lost and attach a copy of the police report. Please attach additional listing if space provided is insufficient. Declaration : I/We hereby declare that these particulars are true to the best of my/our knowledge and belief and I/we have in no manner caused the loss nor by any fraud or misrepresentation sought to benefit thereby. I accept that insurers would be at liberty to deny liability in part or in full if the above written answers are false or inaccurate in any aspect.
Designation
Name
NRIC
Details of Amount Claimed
A) If claim is for repairable damage, give particulars of damage and a tradesman's estimate for the repairs.
B) If claim if for non repairable damage on loss, list items below completing all columns. Supporting estimates for replacement
may be helpful.
Specifications of
property
Lost / destroyed 		Cost Price Where bought
& Date Purchased 		Value at time of loss

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