Burglary Claim

The issue of this form is NOT an admission of liability on the part of the Company. Please answer all questions fully and return form without delay to ALLIANZ NIGERIA INSURANCE PLC

Insurer: * Policy Number E-Mail: *

Date when the loss occurred

Time when the loss occurred

Date of discovery

Who discovered

Address and description of the premises where the loss occurred. State whether Private Dwelling House, Maisonette, Flat, Apartments, Boarding or Lodging House. If Flat, state whether self-contained or not.
State the part of the premises from which the property was stolen. Are you the sole owner of the stolen or damaged property described overleaf? State whether the premises were unoccupied at the time of the loss.
if Yes how long State whether the premises or any part thereof were lent, let or sub-let at the time of the loss. How was entry to the premises effected? Give full details date loss notified to the Police and the name of the address of the police station Have you any suspicions as to parties?
if Yes give details At the time of the loss what was the total value of the whole contents of premises? is the property claimed for insured with any other Company or withUnderwriters against Burglary, Housebreaking, Larceny, or All Risks?
If Yes, give full particulars including name of insurers and Policy number Have you previously suffered a loss by Burglary, Housebreaking or theft?
if Yes, give particulars Insurance Company or Underwriters under a Burglary or All Risks policy
If so please give full particulars

I do solemnly declare that the Property described on the other side belonging to me/us, and insured under the said Policy, was stolen or damaged, and that the amounts severally stated represent the sum. I/We am/are entitled to claim, in terms of the Policy.

I also declare that no other person has an interest in the said Property, whether as Owner, Mortgagee, Trustee or otherwise that is not otherwise insured against All Risks, Burglary, Housebreaking or Theft with this or any other Office or with Underwriters, except as herein mentioned, that I/We have not withheld any material information and that all the statements on this form are to the best of my knowledge and belief correct.

Dated Address
Witness