All Risks Claim

1Claim Information
2Statement of Claim

Name of the Insured

Policy No

Private Address

Telephone No. (private)

Business Address

E-mail Address

Business/Occupation

Fax No

1. Has the property been Stolen, Lost or Damaged?

2. When was the Theft, Loss or Damage discovered and by whom? Please state Date and Time

3. State the circumstances under which the Theft, Loss or Damage occurred

4. When and where was the property last seen by you?

5. If the property has been Lost or Stolen, do you suspect any one? If so, whom?

6. If the property has been Lost or Stolen give the Date that the Police were informed and the name of the Police Station.

7. Are you the sole owner of the property? If not, please give name of the owner.

8. If the property in question is not specifically Insured under the policy but forms part of a miscellaneous item please state the present value of all the property covered under the same item.

9. Is the property covered under any other Insurance? If so, please give full details.

10. Have you sustained any previous Losses by Fire or Theft? If so, please give full details together with the name of an Insurance Company dealing with the loss.

11. Explain in your own words how the Loss/Damage occ

FULL INFORMATION REGARDING THE LOST OR STOLEN ARTICLES MUST BE FURNISHED OVERLEAF.

I hereby warrant the truth of the above statements and of the information shown in the statement of claims.

Full Name

Position

Forms

Others

Country

Proposal+-

Claims

Proposal

Claims

All Risks Claim

FULL INFORMATION REGARDING THE LOST OR STOLEN ARTICLES MUST BE FURNISHED OVERLEAF.

ABOUT ONE NICO CUSTOMER PORTAL