CFS - INSURANCE CLAIM FORM

INSURANCE CLAIM FORM

Please complete the form below to log an insurance claim. Please note that you have 30 days from date of loss to submit a claim to the insurer, claims submitted after the 30 day period may result in repudiation of the claim.
Email Address of person filling in form:*
example@example.com
Where the * appears these fields are compulsory and are required in order for the claim form to be submitted
THE INSURED
The Building Name: (Body Corporate)*
Address: (Street address)*
Unit Number:*
Name of unit owner:

First NameLast Name
Email Address of Owner:*
example@example.com
Cellphone number (Owner)
Cell number
Do you have a tenant in this unit?
Name of Tenant

First NameLast Name
Contact number of Tenant

Area CodePhone Number
If the premises was vacant / not occupied at the time of loss, when last was the premises occupied?
DETAILS OF THE CLAIM
Please insert the date of the loss / damage *

MonthDayYear
Date
Time of Loss / Damage

:HourMinutesAM/PM Option
If the above date of loss occurred more than 30 days ago, please provide a reason for late notification- if applicable
Brief details of circumstances*
Property Damage?
If so, please provide a brief description:*
Policy excess amount:
Amount claimed:
Police case number:
GEYSER DETAIL

(Only applicable to geyser claims)
Code (old):
Code (new):
serial (old):
serial (new):
make (old):
make (new):
size (old):
size (new):
KPA (old):
KPA (old):
PRV (old):
PRV (new):
NRV (old):
NRV (new):
Drip tray:
Drip tray:
THIRD PARTY DETAIL

(Only applicable to third party claims)
Name

First NameLast Name
Address:
Contact number:
ID number:
Vehicle make:
Registration:
Insurance detail:
Supporting Documentation

Supporting Documentation is required in order to process the claim effectively and efficiently. Insurers will not immediately appoint an assessor. An assessor might be appointed after evaluation of supporting documents.
Upload supporting photos of any and all damage/ resultant damage*

Browse Files

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Upload Invoice of repair for cause of loss and quotes for resultant damage*

Browse Files
An invoice of repair to the cause of loss is required. Please ascertain the required documentation from the applicable recipient if the cause of loss had not emanated from your unit. All quotes provided are to be itemised and include square meter of damaged area Cancelof
Upload a contractors report outlining cause of loss and resultant damages*

Browse Files

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Upload a copy of your ID and Proof of bank details(Bank statement/ Bank Letter/Cancelled cheque) for payment upon settlement*

Browse Files
This is required in order to process payment upon settlement of claim Cancelof
Name and Surname of Person who Completed this form.*
Please take note : The acceptance of this form is not itself an admission of liability on the part of the underwriters.
Please note that you will have to pay the contractor directly. No charge will be charged to the levy account unless specifically instructed otherwise by the trustees on a case by case matter
Signature
Should be Empty:

INSURANCE CLAIM FORM

THE INSURED

DETAILS OF THE CLAIM

GEYSER DETAIL

THIRD PARTY DETAIL