• FAST TRACK GEYSER CLAIM FORM

  • Ethics Statement

  • I/We warrant the truth of the answers to the below questions and I/we declare that no information has been withheld.
    By submitting this claim:
    • I understand that the submission of a false claim or any false information relating to a claim constitutes fraud which can result in the claim not being honoured as well as criminal prosecution.
    • I hereby consent to have all information provided by myself in respect of this claim investigated and independently verified.
    • I confirm that all the information provided below is true and correct in every respect.
  • Date
     - -

  • Broker Details

  • Insured Details

  • Format: (000) 000-0000.

  • Loss/Damage Details

  • Commercial and Industrial Acceptances (Pty) Ltd | Reg. No. 2000/019340/07 | VAT No. 4540194349
    Authorised Financial Services Provider Licence No. 13890 | www.cia.co.za
    0861 242 777 | mail@cia.co.za | 13E Riley Road Bedfordview | PO Box 615 Bedfordview 2008
    Directors: DM Haig (Managing Director) | VJ Hayter | PJ Carragher | IE Ismail | J Pienaar | SY van Schoor
    Underwriting Managers for Compass Insurance Company Limited | Reg. No. 1994/003010/06 | VAT No. 4150143289 | FSP No. 12148
    Branches: Johannesburg | Durban | Cape Town | Bloemfontein | Port Elizabeth | Pretoria
  • Date of loss
     - -
  • Size of Geyser
  • Has the geyser burst?

  • Resultant Damage Details

  • Rows
  • Please note: Quotations must contain a detailed description of the damage, the size of the affected area and the cost per square metre. Only one quote is required if the amount is less than R10,000 and two quotes if the amounts are more than R10,000.
  • Have you previously suffered or sustained a loss/damage?
  • Is there any other insurance covering this loss/damage?

  • Payment Details

  • Please note that CIA does not accept responsibility for incorrect banking details supplied.
  • Payee
  •  
  • Should be Empty: