CHARTIS A H Service des Rйclamations Gencon Service des Rйclamations 12501 Old Columbia Pike Silver Spring, MD 20904 888-951-4276 PREUVE DE SINISTRE NUMЙRO.

 

Date loss/damage discovered _ ____ / _____ /_________ Time: am / pm Date vehicle last seen prior to incident _____ / _____ /_________.

 

MOTOR INSURANCE Theft/Fire Report Form If you require immediate advice or assistance in relation to repairs then please ring our Claims Line.

 

POLICY NUMBER CLAIM NUMBER: INSURED Surname / Initials Identity Number If applicable Company Name If applicable Co. Reg. No. If applicable VAT Number Occupation.

 

Motor Theft Claim Form Claim Number Policy Number Broker/Agent Claim number Policy Number.

 

NATIONAL INSURANCE CORPORATION OF TANZANIA LTD. INCORPORATED IN TANZANIA THEFT AND ‘ALL RISKS’ CLAIM FORM Insured Policy No. Name Business or Occupation.

 

Reliance Insurance Company Limited MOTOR VEHICLE THEFT CLAIMFORM The company does not admit liability by the issue ofthis must immediately.

 

NAME NAAM CLAIM NUMBER EISNOMMER INSURER POLICY NUMBER POLISNOMMER VERSEKERAAR AGENT CLAIM NUMBER EISNOMMER MAKELAAR /AGENT.

 

THEFT CLAIM FORM INSURER Insurer PolicyNo. INSURED Company Name / Surname Initials Physical Address Postal Address Code.

 

Office use only MOTOR THEFT/HIJACK REPORT / CLAIM FORM VERSLAG / EISVORM IF THE SPACE ALLOWED IS INADEQUATE, PLEASE EXPAND ON PLAIN PAPER.

 

In associationwith Guardrisk Insurance CompanyLtd PO Box 1051, Kloof ,3640 Tel 031 7645867 Fax 031 7646533 Email leigh leighgroup. co. za MOTOR THEFT CLAIMFORM Claim.

 

MOTOR THEFT CLAIM 5256/105 P of D 02/08 POLICY NO. VAT REGISTRATION NUMBER Eisnommer POLISNR. B. T. W. Versekerde Verklaring Declaration Naam Beroep Address.

 

TRANSURE Ð MOTOR THEFT CLAIMFORM INSURER BROKER / AGENT POLICY NUMBER Name of Insured Address Insured Contact Person Tel. No. Year.

 

NAME NAAM CLAIM NUMBER EISNOMMER INSURER POLICY NUMBER POLISNOMMER VERSEKERAAR AGENT CLAIM NUMBER EISNOMMER MAKELAAR /AGENT.

 

CLAIM REPORTFORM CLAIM NUMBER Office use PROPERTY 29/F, BEATower, M illennium City5, 418Kwun Tong Road,Kowloon, Hong Kong Tel:.

 

MOTOR THEFT CLAIM 5256/105 P of D 02/08 POLICY NO. VAT REGISTRATION NUMBER Eisnommer POLISNR. B. T. W. Versekerde Verklaring Declaration Naam Beroep Address.

 

INSURED DATE TITLE FIRST NAMES SURNAME RESIDENTIAL ADDRESS POSTAL CODE TELEPHONE W TELEPHONE H CELLULAR OCCUPATION EMAIL ADDRESS.

 

Ā Ȁ̀ЀԀĀ؀܀ࠀऀЀ਀܀଀ԀĀ ఀഀ਀̀฀ĀȀༀЀ฀ Ѐ ကᄀ ؀ሀጀ᐀ᔀᘀᜀĀᜀᘀ᠀ᤀ؀ᨓ ᬀ᐀ ᔀࠀሀԀᘓЀᰀ܀ఀ฀̀଀ᴀ ḀሀༀԀఀЀᰀ܀ఀ฀̀଀ᴀ ἀ᐀ ℀᐀ ᰀༀఀ̀ᴀ ∀᐀ ᠀ᄀᄀ଀̀؆ᴀЀ ⌀

 

Policy No: Claim no: 1. Name 2. Address _ _ City: 3. Name of Contact 4. Contact No s: 5. Date Time of. 6. Place of 7. Purpose for which the premises being used.

 

Claims / Claim Form Fire Insurance/ Ver 1. 0/ 1st June 2006 Claim Form Fire Insurance The Issue Of This Form Is Not To Be Taken As An Admission.

 

NATIONAL INSURANCE CORPORATION OF TANZANIA LTD. P. O. Box 9264 DAR ES SALAAM INCORPORATED IN TANZANIA FIRE CLAIM FORM ! , -. / / 0 ! 0 / 0 0 / 1 0 2 33333333333333 / 333333333333333 333333333333333 - 99 Fire claim.

 

IFFCO-TOKIO GENERAL INSURANCE COMPANY LIMITED REGISTERED OFFICE: 34, NEHRU PLACE, NEW DELHI – 110019 Claim No. : _____________ Date of Issue: __________.

 

,x “Ьh Ааc JД A ю„т Kз Й ў JГЗ ’я9эК.

 

ROYAL SUNDARAM ALLIANCE LIMITED 46,Whites 014. Phone No:044-851 5500, Fax: 044-851 1750 e-mail : royalsundaram vsnl. net The issue of this.

 

Annexure II The issue of this form is not to be taken as an adm ission of liability. Please ensure that all columns of the claim forms are filled in by the insured and no column.

 

Ā Ȁ̀ЀԀĀ؀܀ࠀऀЀ਀܀଀ԀĀ ఀഀ਀̀฀ĀȀༀЀ฀ Ѐ ကᄀ ؀ሀጀ᐀ᔀᘀᜀĀᜀᘀ᠀ᤀ؀ᨓ ᬀ᐀ ᔀࠀሀԀᘓЀᰀ܀ఀ฀̀଀ᴀ ḀሀༀԀఀЀᰀ܀ఀ฀̀଀ᴀ ἀ᐀ ℀᐀ ᰀༀఀ̀ᴀ ∀᐀ ᠀ᄀᄀ଀̀؆ᴀЀ ⌀

 

Claims / Claim Form Fire Insurance/ Ver 1. 0/ 1st June 2006 Claim Form Fire Insurance The Issue Of This Form Is Not To Be Taken As An Admission.