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    PROPERTY LOSS-DAMAGE CLAIM FORM v1 0

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    Fabian Jadue
    The insured, Mr. F.A. Jadue Fagres, is claiming for property loss/damage that occurred on May 27, 2023 at the Houghton Golf Club. Mr. Jadue claims that while at the golf club, he obtained a hole in one, but in doing so damaged the hole which will cost an estimated R3,000 to repair. This is the only item being claimed for in the amount of R3,000. Mr. Jadue declares that all information provided in the claim form is accurate and complete.

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    PROPERTY LOSS-DAMAGE CLAIM FORM v1 0

    Uploaded by

    Fabian Jadue
    28 views2 pages
    The insured, Mr. F.A. Jadue Fagres, is claiming for property loss/damage that occurred on May 27, 2023 at the Houghton Golf Club. Mr. Jadue claims that while at the golf club, he obtained a hole in one, but in doing so damaged the hole which will cost an estimated R3,000 to repair. This is the only item being claimed for in the amount of R3,000. Mr. Jadue declares that all information provided in the claim form is accurate and complete.

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    The insured, Mr. F.A. Jadue Fagres, is claiming for property loss/damage that occurred on May 27, 2023 at the Houghton Golf Club. Mr. Jadue claims that while at the golf club, he obtained a hole in one, but in doing so damaged the hole which will cost an estimated R3,000 to repair. This is the only item being claimed for in the amount of R3,000. Mr. Jadue declares that all information provided in the claim form is accurate and complete.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    28 views2 pages

    PROPERTY LOSS-DAMAGE CLAIM FORM v1 0

    Uploaded by

    Fabian Jadue
    The insured, Mr. F.A. Jadue Fagres, is claiming for property loss/damage that occurred on May 27, 2023 at the Houghton Golf Club. Mr. Jadue claims that while at the golf club, he obtained a hole in one, but in doing so damaged the hole which will cost an estimated R3,000 to repair. This is the only item being claimed for in the amount of R3,000. Mr. Jadue declares that all information provided in the claim form is accurate and complete.

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    © All Rights Reserved
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    PROPERTY LOSS/DAMAGE CLAIM FORM

    Broker/Insurer Name HULLEY GARRUN INSURANCE BROKERS Policy No. RGT61134 Claim No.

    Name and Occupation MR F A JADUE FAGRES

    Identity Number 2 3 1 1 1 9 8 8
    Insured

    101 Argyle Avenue, Hurlingham, Unit 43. Sandhurst Estate


    Address and (day) telephone number SANDTON
    2196

    Date and time of loss/damage When was loss/damage discovered?


    Occurrence
    Damage
    Loss/

    27/05/2023
    Loss/Damage Place

    Place where loss/damage occurred Houghton Golf Club

    Were premises occupied? Yes No If No, when last occupied?


    INSURED
    If Yes, By whom?
    Purpose of occupation PERSONAL

    OBTAINED A HOLE IN ONE


    Describe in detail how the loss or
    Cause of Loss/Damage

    damage occurred stating how (if


    applicable) entry was gained to
    premises

    If loss/damage was caused by another N/A


    party provide name and address

    Have you previously suffered


    Previous
    Loss/Da

    loss/damage? Yes No REFER TO YOUR RECORDS


    mage

    If Yes, give details and name of insurer


    Police

    Police reference number NOT REPORTED Police Station Date Reported

    Does any other party hold an interest


    Interest

    in the insured property, e.g. credit


    Other

    agreement? Yes No
    If Yes, give name and interest
    Is there any other insurance covering
    Insurance

    this loss/damage? Yes No


    Other

    If Yes, give name of insurer

    You may select, for added security, payment of any amount due to you directly into a bank account. Please specify the name of the bank, branch, name of
    account and account number.
    Payment method

    Name of Bank FIRST NATIONAL BANK Branch name FNB ELECTRONIC PAYMENTS

    Name of Account Holder F A JADUE FAGRES

    Account Type CHEQUE Branch Code 2 5 0 6 5 5 Account No. 6 3 0 0 8 6 6 6 9 8 5


    I/We solemnly declare that I/we have suffered loss of or damage to the property enumerated above and on the reverse hereof and that the said property was in my/our possession
    immediately prior or during the said loss/damage which occurred in the circumstances described above. I confirm that all the questions were completed honestly and fully by
    me/us. I understand that the accuracy and effectiveness of this Claim Form is dependent on the quality and accuracy of the information I provide.
    Digitally signed by
    8397DFC2B8154E4 8397DFC2B8154E408F6CBE2B2
    08F6CBE2B280551 805517F
    Date: 2023.06.02 10:29:42
    Insured’s signature 7F +02'00' Capacity INSURED Date

    22/06/2017 Property Loss/Damage Claim Form v1.0 Page 1 of 2


    STATEMENT OF PROPERTY LOST, STOLEN OR DAMAGED

    N.B. – Claims in respect of damage to buildings must be accompanied by a builder’s estimate.

    Insurers share information with each other regarding domestic policies and claims with a view to prevent fraudulent claims and
    obtain material information regarding the assessment of risks proposed for insurance.
    Please refer to the Consent Clause on the policy schedule for more details in this regard.

    Deduction for wear and


    From whom purchased or Value Amount claimed
    No Description of property Date acquired tear or depreciation or
    acquired (Rands) (Rands)
    value of salvage (Rands)
    1. HOLE IN ONE 3,000.00

    2.

    3.

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    5.

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    22/06/2017 Property Loss/Damage Claim Form v1.0 Page 2 of 2

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