ADDSURE ONLINE CLAIM FORM GENERAL

1
Name of scheme
2
Policy number
3
Address of scheme
4
Section or Common Property (CP)choose one
Please Select
Please Select
Section
Common Property (C.P.)
5
Door number
6
Submitter of this form - name
7
Email of person submitting * This field is required.Important - so that you receive a copy
example@example.com
8
Were the premises occupied?
YES
NO
9
If no, when last occupied?
Date
Day
Month
Year
10
Occupied by whom?
Please Select
Please Select
owner occupied
tenant occupied
unoccupied
11
Occupation purpose
Please Select
Please Select
Residential
Commercial
Industrial
12
Contact name
13
Contact phone
14
Contact designation
Please Select
Please Select
Owner
Trustee
Tenant
Portfolio Manager / MA
Other
15
Contact emailImportant - required for form return
example@example.com
16
Other contact infoAnyone else / alternate for contact - if required
17
Date of loss
Date
Day
Month
Year
18
Approximate time of lossapproximate time of the event
19
When discovered?
Date
Day
Month
Year
20
Approximate time of loss discoveryapproximate time
21
Detailed description of damage to propertyList damages with amounts if known eg. 10 sqm of collapsed ceiling R10,000
22
Estimated Loss RPlease state rough estimate of loss or total of repair quotations
23
What caused the loss or damage?e.g., storm, wind, hail, fire, flooding plus some detail about occurrence.
24
Is the damage caused by a vehicle impact?
YESNO
25
SAPS case numberIf "NO", this question will not appear
26
Police station
27
Date reported
Date
Month
Day
Year
28
Damage by whom?
29
Address of 3rd party
30
Additional information
31
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.
32
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Cancelof
33
Trustee 1 name
34
Date of trustee 1 signatureif available otherwise "next"
Date
Day
Month
Year
35
Trustee 1 signatureif available otherwise "next"
Clear
36
Trustee 2 name or managing agentif available otherwise "next"
37
Date of trustee 2 or managing agent signatureif available otherwise "next"
Date
Day
Month
Year
38
Trustee 2 signatureif available otherwise "next"
Clear
39
Section owner or witness
40
Date of owner or witness signature
Date
Day
Month
Year
41
Signature of owner or witness
Clear
Should be Empty: