Free General Claim Form

This General Claim Form sets out the specifics of an insurance claim. This form contains the name of policy holder, policy number and agency, amount insured and insurance period. Specifics regarding the claim include date and time when loss or damage occurred, where the loss occurred, by whom the loss was discovered and any particulars on how the loss or damage occurred. This form is signed by the insured who declares that the information provided is true and accurate.

Disclaimer:This was not drafted by an attorney & should not be used as a legal document.




GENERAL CLAIM FORM

POLICY NO: _______________________ AGENCY: ____________________________________
AMOUNT INSURED: ____________________ PERIOD OF INSURANCE: _____________________
NAME: ___________________________ OCCUPATION: ________________________________
ADDRESS: _________________________ TELEPHONE NO: ________________________________

1. Date and time when the loss or damage occurred
____________________________________________________________________________
2. Premises where loss or damage occurred
______________________________________________________________________________
3. By whom the loss or damage discovered
______________________________________________________________________________
4. Particulars or details how the loss or damage occurred
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
5. Purposes the premises being used
______________________________________________________________________________
6. If any alteration in risk had taken place since policy was issued or last endorsed, please give details.
______________________________________________________________________________
7. Were the premises occupied at the time?
______________________________________________________________________________
8. If not, on what date and at what time were they last occupied?
______________________________________________________________________________
9. For how long has the premises been unoccupied since the policy was effected or last renewed?
______________________________________________________________________________
10. Are you the owner of the premises or responsible for the repairs?
______________________________________________________________________________
11. Is there evidence of forcible entry of the premises?
______________________________________________________________________________
12. Are there any other insurances on the property?
______________________________________________________________________________
13. If so, specify the name of the Company, Policy Number and amount.
______________________________________________________________________________
14. Have you ever before sustained a loss of this nature?
______________________________________________________________________________
15. Is any other person interested in the property as Owner, Mortgagee, Trustee or otherwise?
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I hereby declare that the information provided above is a full, true and accurate statement. I further declare that the property, which is insured under the above named Policy or Policies, was destroyed or damaged as aforesaid according to the extent and values stated. Hereby I claim the sum of the amount mentioned herein.
Date __________________________________
Signature of Insured ______________________



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