Material Damage 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

Immediate Notice Must Be Given To The Police

1Details of insured Insured's Name: * Policy Number Address Contact Person E-Mail: * Telephone Number *

2 Details of loss/damage

Date of loss/damage

Time of loss/damage

Address where loss/damage occured Detailed description of how the loss occured Email

Declaration

I/We
Position of the insured and on behalf and on behalf of the insured declared above answers to be true and correct AND acknowledge that the insurer may make its decision on indemnity having regard to these answer

Signature

Date

3 Statetement of claim

N.B: - The amount to be claimed on any article is limited to the actual intrinsic value at the time of the loss. The extent of damage should be stated as fully as possible

Full Description of Property

Cost Price

Amount Claimed