Declaration

I/We warrant the truth of the answers to the questions below and I/we declare that no information has been withheld and that the amount claimed represents my/our loss arising from the stated occurrence. By submitting this claim I declare herewith that I am the Insured in terms of this policy.

[* Indicates required fields]

Policy number:
Insured's lastname and initials, or company name:*
Insured's e-mail address:
Phone number - Home:
Phone number - Work:
Cellphone number:
Insured's Identity Number:
Date:*
Time:
Type of claim:
Describe fully how the loss or damage occurred:
Address line 1:
Address line 2:
Address line 3:
City:
Province:
Postal code:
The description and value of each item claimed:*
Was the loss or damage reported to the police?


Date:
Please state where you reported the event and to whom (name):
SAPS Case Number:
I certify that the above information is correct.*

I certify that I agree to the Declaration.*


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