(The issue of this form is not to be taken as an admission of liability by the Insurers)
Name of Policyholder
Policy No
Contact Person
Tel No
Details of Accident
Where it occurred?
Date : Time :
Describe fully how it occurred :
Names and addresses of witnesses (It is most important that the name of
every witness should be furnished:-
  1. of
  2. of
If the loss could have been prevented, state what precaution might have
been taken:
To which Police Station was the loss reported? (Please attached Police report)
Have you any suspicions as to parties implicated?
What steps have you taken to prevent a recurrence?
State other insurance in force covering the property mentioned herein.
State the total value of cash in hand at date of loss (include supporting documents)
Have you previously sustained a loss under similar circumstances? If so, give particulars
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.

Please note that all personal information provided to TMiS is subject to the Personal Data Protection Policy Statement posted at under privacy statement.