Money Claim

No 2 The Colosseum Building
Century City  Boulevard

 Century City

PO Box 90 Century City 7446
Tel: (27) (21) 529 7800 
Fax: 0865 202 355
E-mail: insure@aib.co.za
 Insured
Name
Surname
Address
Telephone
Fax
E-mail
Business, occupation or profession
Policy Number
 Details of Loss
Amount of loss
Please indicate how money was made up
Cash
Banknotes
Open cheques
Crossed cheques
Postal Stamps
Revenue Stamps
Open Postal Orders
Crossed Postal Orders
Money Orders
Date and time of loss
Place of loss
Usual hours of business
Where was cash lost? In actual transit
From locked safe
From locked strong room
If loss from safe state:
Make
Size
Is it built into wall? Yes    No
Give particulars of any damage to safe or strong room
Was loss reported to police? Yes    No
If yes, when?
To which police station?
Do you suspect anyone in particular? Yes    No
If yes, whom?
Do you hold any other insurance covering this loss? Yes    No
If yes, give particulars of policy and insurer
How did the loss occur?
What steps do you propose taking to prevent a similar loss in the future?
 Authority for payment
It is recommended that any amount payable to you directly be transmitted by Electronic Bank Transfer for speedier settlement and security reasons.
Do you agree to this? Yes     No
 Signature
Name
Signature
Please print the completed form and fax the signed document to 0865 202 355