(The issue of this form is not to be taken as an admission of liability by the Insurer. Fire GA Claims Fax No: 62259887)
Name of Policyholder
Policy No
Contact Person
Tel No
Title of Contract
Location & Address of Contract Site
Name of supervising engineer
Supervising Engineer Tel No
Section 1
Which items were damaged/loss?
Contract Works Construction Plant and Equipment Construction machinery
Please describe fully
Date and time damage/loss occurred: @ about
Date and time damage/loss discovered: @ about
Damage was discovered by:
How did the damage occur and what was its probable cause? (Attach sketches, photos, etc)
How far had the construction of the damaged Item(s) progressed at the time of the occurrence of the damage?
Will any alterations/improvements be made to design, construction or material when repairs are carried out?
What are the estimated costs to repair/replace damage/loss (as the case may be)
Contract works Construction Plant & Equipment Construction Machinery
Section 2
Is a Third party liability involved? If so, give:-
a) Name and Address of any persons injured or the owner of the property damaged :
b) Have you received Notice of any claim?
Give particulars and enclose all correspondence/documents that you have received.
c) Was a report lodged with the Police? If so, give report number and police station & attach a copy of the report.
Are existing buildings or surrounding properties damaged?:
Please give details of other policy/policies in force (if any)
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.

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