MACHINERY INSURANCE CLAIM FORM
Policy No Claim No
1. INSURED
Name
Address
2. DETAILS OF INSURANCE
Name of Insured
Policy No(s)
Sum Insured
Period of Insurance
N.B. If Insurance is effected with other Companies, copies of such policies to be submitted to the Company.
3. DETAILS OF LOSS
Time & Date of Loss/damage
Causes of Loss
Details of affected (items)
Has the Loss been reported to any Engineer ?
4. EXTENT OF LOSS
We hereby declare that the statements made by us in the claim form are true to the best of our knowledge and belief and that we have not withheld any material information which has a bearing upon the claim.
Place
Date
SUBMISSION OF THIS FORM DOES NOT BIND COMPANY FOR LIABILITY