Property / Liability Claim Form

1.  Personal Particulars Name of Insured: NRIC: (e.g. For S'porean 1234567A) Address: Postal Code: Tel: Fax: Business/Occupation: For Business/Company: Are you GST registered Yes No Policy No: Policy Type: --Select-- Home Insurance Golfers Insurance Pet Insurance Fire Insurance Business Plate Glass Fidelity Guarantee Money Theft Public Liability Bailee's Liability All Risk Contractors All Risk Marine Hull Marine cargo Others: Email:   2.  Details of Occurrence Date: (dd-mm-yyyy) Time: Place: Please give an account of how the incident occurred: Please give particulars of person responsible for the loss/damage/injury Have you made a claim upon the person responsible for the loss/damage/injury? Yes No If claim for damage/loss is arising from theft/malicious act, please give us details of where and when the police report was made. How was entry into premises gained? Was there any signs or evidence of forcible and violent entry? Was the premises occupied at the time of the occurrence? If not, when was it last occupied? Particulars of eyewitnesses, if any. Please give us particulars of persons other than yourself who have any interest in the property concerned and state the nature of their interest. Are there any other insurance policies covering the property concerned? If yes, please give details: Please state the current total value of all the property which is insured under the policy:   3.  Liability Claim    (This section should be filled only if a claim is being made against you.) When were you first notified of the incident? If anyone has been injured, please give: a) full particulars of person injured b) details of injuries sustained If loss/damage/injury is attributed to defects in your Premises, equipment or plant, please give us details Has any intimation of claim been made against you? If so, by whom? (Please give details of the claim amount in Section IV) NOTE: No payment, offer or promise of any payment or admission of any liability should be made. All letters from third parties should be forwarded to us immediately upon receipt.   4.  Details of Claim Description of Item Details of Damage/Loss Date Purchased/Incurred Cost S$ Amount Claimed S$ Name: NRIC: Date : 03-12-2008