Property Loss / Damage 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
Occupation
Policy Number
 Details of loss/damage
Police reference number and station
Date reported
Date and time of loss/damage
When was loss/damage discovered
Address where loss or damage occurred
Were the premises occupied? Yes    No
If yes, by whom?
Purpose of occupation
If not occupied, when last occupied?
Describe fully how the loss/damage occured and, if applicable, how entry was gained to the premises
Was burglar alarm activated? Yes    No
If loss/damage caused by another party, give name and address
Have you previously suffered loss or damage? Yes    No
If yes, give name of insurer
Any other party interest in the property? Yes    No
If yes, give name and interest
Any other insurance covering loss/damage? Yes    No
If yes, give name of insurer
Estimated total value of all property insured
When last valued?
 Statement of property lost, stolen or damaged
 In case of damage to buildings, a builder's estimate has to be faxed to us
Number Description Date acquired From whom purchased or acquired Current replacement value Deduction for wear and tear or depreciation (if applicable) or value of salvage Amount claimed
 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