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Broker Details

Details of Insured

Loss/ Damage Occurrence

Loss / Damage Place

Cause of Loss//Damage

Previous Loss / Damage


Other Interest

Other Insurer


Statement of Property Lost, Stolen or Damaged

N.B: Claims in respect of damage to buildings must be accompanied by a builder’s estimate.

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PLEASE NOTE: By clicking "Submit Claim Request" you hereby solemnly declare that the information above and on the face hereof is a true and faithful account of the event/damages sustained and that to your knowledge nothing has been concealed which may be relevant to consideration of this claim.