Property Claim Form

Title

Dr Mr Mrs Ms

Insured Name

Address

Address at which the damage occurred

Date of occurrence

Policy No

Town/Village

Contact No

Town/Village at which the damage occurred

Time of occurrence

Cause of the Damage

N.B. In case of Fire the exact cause of the outbreak should be clearly stated.

Is the claim is in respect of the building

Yes No

Are there any other insurances upon the same property?

Yes No

PARTICULARS OF CLAIM

Full Description of each item of property damaged or destroyed.

Original cost price

Date of Purchase

Value immediately previous to the damage

Value of Salvage

Amount claimed after deduction of salvage and allowance for depreciation

Remarks

IMPORTANT: This form should be completed and forwarded to the company as soon as possible and in no case later than 30 days from the date of the occurrence. Claimants are advised to read the condition of the company’s policies regarding claim before completing this form.

NOTES

BUILDING claims, including damage to decorations, should be based on a builder’s estimate and columns (2) - (5) need not be completed.

CONTENTS claims, All columns should be completed and an indication of the extent of the damage given. If any of the items are capable of repair the claim should be based on a Tradesman’s estimate. Cost price at the time of loss or damage (after deductions of all discounts and trade allowances for cash payments) are alone recognized in estimating sound values in respect of claims for Stock-in-Trade. Estimates should be submitted to the company before instructions are given for the work to be put in hand and if possible should accompany this form.

I declare that the property detailed overleaf and insured under the above policy was destroyed or damaged as stated and in consequence a claim is hereby made for the sum or sums stated herein and I further declare that no other person has any interest in the said property except:

Name

Date

Property claim Form

PARTICULARS OF CLAIM

NOTES

Netherlands Insurance

Frequently Asked Questions

Netherlands in Antigua

Office Hours – Grenada

Office Hours – Antigua