Assignment

YOUR DETAILS

Full name (company name if applicable)



Address (company address if applicable)



Telephone Number (company telephone number if applicable)



E-mail address

CONTACT

Home



Business



Cell / Mobile



Fax Number



E-mail Address

LOSS DETAILS

Date and Time of Loss



Nature of Claim / Type of Loss



Location of Loss



Special Instructions

INSURER’S DETAILS

Insurer’s Name



Instructor / Assigned by



Insurer’s Claim Reference Number



Broker’s Reference Number (if applicable)



Name of the Insured



Insured’s Address

POLICY DETAILS

Policy Number



Policy Type/Coverage



State the value of insured's property * Buildings



Machinery & Plant



Furniture, Fixtures, Fittings and Decoration



Stock



Loss of Profit



Others



Warranties / Endorsements



Policy Excess