FlexSpacez • Incident Form

Incident Form

This form is NOT an admission of liability by the Company.

Please answer all questions fully and return form without delay.

1. Basic Information

Insured *

Policy Number *

E-Mail *

Date and Time of Loss

Details of Circumstances Leading to the Loss

Location Where Loss Occurred

Date of Discovery of Loss

Date Notified to Police

Name and Address of Police Station

Suspicion of Involvement? (Give Full Particulars)

Is Property Insured with Any Other Company?

Previous Loss from Burglary or Theft? (Give Particulars)

Previous Claims under Burglary or All Risks Policy?

Declaration

I do solemnly declare that the Property described on the other side belonging to me/us, and insured under the said Policy, was stolen or damaged, and that the amounts severally stated represent the sum I/We am/are entitled to claim, in terms of the Policy.

I also declare that no other person has an interest in the said Property... all statements on this form are to the best of my knowledge and belief correct.

Date

Signature of Claimant

Address

Witness

Statement of Claim

N.B. The amount to be claimed is limited to actual value at the time of the loss. State damage extent clearly.

Property Description	To Whom It Belonged	When Bought	Cost Price	Amount Claimed