Claim Form AdminPlus

MOBILE DEVICE CLAIM FORM

NOTE: Our claims process starts with the completion of this form.
All lost/stolen Mobile Devices must be reported to the SAPS within a maximum of 48 hours from discovery of the loss. This form must be submitted to Administration Plus (Pty) Ltd within 30 days from the date of loss.
CLAIMS DECLARATION - PLEASE COMPLETE IN FULL
INSURED:*
CONTACT PERSON:*
CONTACT TEL:*
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
EMAIL ADDRESS FOR CORRESPONDENCE:*
PREFERRED COLOUR:
Your preferred colour for new/replacement device. Please note that colour is not guaranteed
DEVICE CLAIM DETAILS
StolenDamagedLostRepair
Date / Time of Loss:*

DayMonthYearHourMinutes
Place of Loss:*
What happened?
Details of the incident of loss or damage.
S.A Police Station Name:
S.A.P Case Number:
Date Reported:

DayMonthYear
THEFT FROM VEHICLE

Fax or e-mail a copy of the invoice for repairs to your vehicle to: 086 505 6721 / claims@adminplus.co.za
How was entry gained?:
YesNo
ITC Reference Number:
I understand that I am fully bound by my conscience in making this statement and that any misrepresentation of the facts constitutes fraud. I have no other insurance on the property claimed for above. I hereby agree that the Insurers of the Policy may take over and conduct this prosecution for their own benefit of any claim for cover or otherwise and shall have full discretion in the conduct thereof.
Validation by Electronic Signature:

Note: your IP address is recorded for security purposes.
Today's date

DayMonthYear
Full Name:*
South African ID Number:*
Address: 29th floor The Box, 9 Lower Burg Street, Cape Town, 8001-Telephone no: 086 111 8765
Reg. No. 2004/023852/07-Vat No. 4190243008-FSP No. 36841
E-mail:claims@adminplus.co.za
Administration Plus (Pty) Ltd FSP No 36841 Underwriting Managers on behalf of Constantia insurance Company Ltd FSP No 31111. Authorised Financial Services Providers
Should be Empty:

CLAIMS DECLARATION - PLEASE COMPLETE IN FULL

DEVICE CLAIM DETAILS

THEFT FROM VEHICLE

Validation by Electronic Signature: