NOTIFICATION of LOSS or DAMAGE for
CONTRACTORS' ALL RISKS INSURANCE

Claim No:
(for official purpose only)		   Policy No:
SUBMISSION OF THIS FORM DOES NOT BIND COMPANY FOR LIABILITY
1. Title of contract insured:  
  Name (s) and address(es) of Insureds(s):s  
  Location and address of contract site:  
  Name of Supervising engineer:

  
  Nearest railway station/ airport :  
  Easiest access to contract site from railway station/ airport  
2. When did the loss occur?   Time:
      Date: dd/mm/yy
3. What was damaged?  
  Explanation (which part? to what extent?)
  
4. Has damage occured to third parties?

5.
 How did the loss occur and what was the probable cause? (Please append sketches, photographs, and if available, amounts of rainfall, water levels, rates of flow, police reports and newspaper cuttings)


6.
 Are there any witnesses to the occurance of the loss?

  If so please give names, professions and addresses.
 
7. How are the damaged itmes to be repaired? Estimated time?
  
8. Are any alterations to or improvements of design, execution or construction materials being effected whilst repairs are being made?
  
9. Is overtime and/ or night work or work on public holidays or express freight involved in order to repair the damaged items? If so, to what extent and why?

  
10. What are the estimated repair costs for damages to
   ?
11. What is the estimated indeminity for third party liability claims?
  
12. Were any existing buildings or surrounding property damaged? If so, by what?
  
  Estimated claims amount  
13. Remarks
  
We declare that we have answered the above questions conscientiously and truthfully.
Date: