ADDSURE ONLINE CLAIM FORM GENERAL

1
Name of scheme* This field is required.This is the name of your complex e.g. ABC MEWS
2
Address of scheme
3
Insurere.g. CIA, CIB, Santam, Bryte, Hollard, Rodel, Old Mutual,etc.
4
Policy number
5
Section or Common Property (CP)choose one
Please Select
Please Select
Section
Common Property (C.P.)
6
Door number* This field is required.
7
Submitter of this form - name* This field is required.
8
Email of person submitting * This field is required.Important - so that you receive a copy
example@example.com
9
Were the premises occupied?
YES
NO
10
If no, when last occupied?
Date
Day
Month
Year
11
Occupied by whom?
Please Select
Please Select
owner occupied
tenant occupied
unoccupied
12
Occupation purpose
Please Select
Please Select
Residential
Commercial
Industrial
13
Contact name* This field is required.
14
Contact phone
15
Contact designation
Please Select
Please Select
Owner
Trustee
Tenant
Portfolio Manager / MA
Other
16
Contact emailImportant - required for form return
example@example.com
17
Other contact infoAnyone else / alternate for contact - if required
18
Date of loss* This field is required.
Date
Day
Month
Year
19
Approximate time of lossapproximate time of the event
20
When discovered?
Date
Day
Month
Year
21
Approximate time of loss discoveryapproximate time
22
Detailed description of damage to property* This field is required.List damages with amounts if known eg. 10 sqm of collapsed ceiling R10,000
23
Estimated Loss RPlease state rough estimate of loss or total of repair quotations
24
What caused the loss or damage?* This field is required.e.g., storm, wind, hail, fire, flooding plus some detail about occurrence.
25
Is the damage caused by a vehicle impact?
YESNO
26
SAPS case numberIf "NO", this question will not appear
27
Police station
28
Date reported
Date
Month
Day
Year
29
Damage by whom?
30
Address of 3rd party
31
Additional information
32
Please read this before signing:

CLAIM SUBMISSION DETAILS AND SIGNATURES

This claim submission should be signed in terms of PMR10 (signing of documents Addsure accepts the claim form in good faith i.e. that the person signing confirms that they are mandated accordingly. Any personal information provided by the policyholder and/or its representatives in terms of this insurance policy and this claim will be used:

By the underwriting manager, insurer, broker, loss adjuster, their employees and service providers for the acquittance of this claim and will be kept on record as required by legislation and for recordkeeping needs. To confirm risk information, risk management data, information from public sources including but not limited to addresses, and to verify ownership. To comply with legal and regulatory requirements as well as industry codes We will take all reasonable steps to ensure that all personal information is used, processed and stored in accordance with the relevant legislation, including but not limited to PAIA and POPIA. I/we hereby confirm that all of the personal information provided above is accurate and is suppled voluntarily. I/we hereby authorise processing of my personal information as set out above and I understand the purposes for which it required. I/we hereby confirm that the particulars and declarations are correct and complete and include all information known to me/us It is further declared and understood that where this application is completed by the managing agent or other agent of the insured, the managing agent or other agent will be considered to have been authorised to act as the insureds agent for purposes of completing this claim submission.
33
File UploadMax 100 MB - please no zip files - please email separately if more
Drag and drop files here
Select files to upload
Cancelof
34
Trustee 1 name
35
Date of trustee 1 signatureif available otherwise "next"
Date
Day
Month
Year
36
Trustee 1 signature* This field is required.if available otherwise "next"
Clear
37
Trustee 2 name or managing agentif available otherwise "next"
38
Date of trustee 2 or managing agent signatureif available otherwise "next"
Date
Day
Month
Year
39
Trustee 2 signatureif available otherwise "next"
Clear
40
Section owner or witness
41
Date of owner or witness signature
Date
Day
Month
Year
42
Signature of owner or witness
Clear
Should be Empty: