Claim form
General									
Zurich Insurance Company Ltd. (Singapore Branch) (the “Company”) does not admit liability by the issue of this form. 
It is issued to enable the insured to lodge a written statement of claim

Branch
Policy No. Due Date

Broker/Agent
Address

CLAIM NO. (Office use only)                                                                  TYPE OF INSURANCE COVER

   Important information 	
●      Do not admit liability - Ask for any claim to be put in writing and refer all correspondence to ZURICH INSURANCE COMPANY LTD
       (SINGAPORE BRANCH).
●      Make sure you give us all the details about your claim. Attach a separate sheet if you have insufficient space on this form.
●      Send all quotations you have received to repair or replace damaged property or invoices or receipts if the goods have already been repaired. 

  Insured

Name of Insured

Address 	

Company Registration No (where applicable)                                                  
Business/Occupation                                                                    Phone Number                                      E mail Address
Date of incident	/	/	Time 	am/pm

Where did the accident occur?

Describe as fully as possible how the incident occurred.

Do you consider any other party responsible for the incident?       Yes 	No	 If 'Yes', give details

l in all relevant sections (Please PRINT your answers)

Are you the sole owner of the property lost or damaged?	Yes	No
If 'No', give full details of the owners or part owners

Do you hold any other insurance under which a claim for this incident may be made?	Yes	No
If 'Yes', give full details

Have you previously (in past 3 years) made a claim against any insurance company?           Yes	 No

	
	
Schedule of property	

Description of property lost or damaged
(state each article/item separately)	When and where purchased	Purchase price
$	
Present cost of 
replacement	Depreciation for age and condition	
Amount claimed	
		
$			
$	
		$			$	
		$			$	
		$			$	
		$			$	
		$			$	
		$			$	
		$			$	

 	Total amount claimed 	
$	

Special Risks, Burglary and Theft, Malicious Damage Claims. 
Note: Police complaint acknowledgement forms to be attached to all cases of theft or loss.
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Have police been informed of the incident?         Yes  	       No 
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Police Station reported to 	Report Number
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If 'No', please give reason

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Has the loss been advertised in the newspaper?     Yes	         (please attach newspaper cutting)      No
Details of any other steps taken to recover the article

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Describe the method of entry and the damage caused to the building

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When were the premises last occupied?

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Who was on the premises at the time of loss?

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For Glass, Wash Basin and Lavatory Pan Breakage Claims Only
Was the glass, basin, etc., cracked prior to the incident?	Yes	No	If so, state date	/	/

For fire or impact by vehicle claims only
If a dividing fence or party wall was damaged, give name and address of joint owner

If damage was caused by a vehicle, give details of owner/driver and vehicle registration number

For storm and tempest and water damage claims only
Note: Do not delay in taking necessary action, such as emergency repairs, to prevent further damage
What steps have been taken to minimize damage?

Has the building been physically damaged?	Yes	No
If 'Yes', give details (e.g. roof sheeting and/or tiles damaged)

If there has been no physical damage to the building, give details of how water entered the premises

   Evidence of ownership and value 	
Please attach your receipts or other documents to establish evidence of ownership and the value of each item. In cases of equipment or property e.g. bicycles, television receivers, supply evidence of serial numbers for our confirmation to manufacturers and the police.
Damaged property must not be disposed of until authorized by Zurich Insurance Company Ltd (Singapore Branch).

WARNING: Wilful or reckless exaggeration or inflation of the amount claimed may forfeit the claim.

   Declaration 	 
•	I / We hereby declare that all the information and particulars given above are true and complete to the best of my/our knowledge and belief and they are made without reservation of any kind, that no other person(s) have an interest of any kind in the said property and that all conditions and stipulations of the policy have been complied with.

•	I/We hereby claim from the Company in respect of the said loss, damage or accident and declare that the amount claimed above is based on a true value at time of the loss.

•	I / We hereby acknowledge, consent and agree that –

i.	the Company may collect, use and disclose all personal data provided or as may be provided by me/us and through other sources as the Company deem relevant from time to time for the purposes as contemplated in this form including but not limited to policy servicing, processing, handling, administering, claims investigations, claims analysis, fraud evaluation, prevention and control, and/or any work put towards settling my/our claim with the Company or other insurers;  

ii.	the Company may disclose the personal data to third parties (whether in or outside Singapore) including but not limited to consultants, fraud detection agencies, the General Insurance Association and its members, regulators, law enforcement bodies and government agencies and/or authorities for the purposes as set out in this form; 

iii.	the personal data protection clauses herein (“DPC”) are not exhaustive. By signing this form, I/we declare that I/we have read, understood and agreed to be bound by the prevailing Personal Data Protection Policy available at http://www.zurich.com.sg/pdpa (“Data Protection Policy”) which is to be read together with the DPC. If there is any discrepancy between the DPC and the Data Protection Policy, the DPC shall prevail only to the extent of the discrepancy;     

iv.	if I / we provide third parties’ personal data (e.g. information of the life assureds, insured persons, beneficiaries, beneficial owners, dependents, spouse, children, parents, siblings, customers, prospects, payees and/or employees) to the Company, I / we represent and warrant to the Company that prior consents have been obtained from each of the third parties for the collection, usage, disclosure and processing of their personal data in the manner as set out above and the Data Protection Policy; and

v.	I / We shall indemnify the Company for all losses and damages which may be suffered by the Company arising out of the breach of the declarations, representations and/or warranties herein. 

Name & Signature (with company’s stamp, if applicable)	Date
✗	/	/

Item	
When Purchased	
Original Cost	Replacement
Cost	
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