Claim form
Machinery Breakdown/Deterioration      of Stock/Fusion                                                
The 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.

CASE/CLAIM NUMBER

   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 details – Please print you answers
Full name of insured – Mr, Mrs, Miss, Ms

Surname	Given name(s)

Address 	

Company Registration No.	Business	
Policy number	
Phone number 	

Mobile	Fax/E mail address

Date of loss	/	/	Time 	am/pm

Where did loss occur?

Describe as fully as possible how loss occurred

Insured details (continued)   

Do you consider any other party responsible for the loss?                                           Yes          No
If 'Yes', please state why?

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

Do you hold any other insurance under which a claim for this loss may be lodged?    Yes          No
If 'Yes', please give details

Name and type of appliance to which motor is attached

Who was it purchased from?

Date of Purchase	/	/	Price $

Is the motor under a manufacturer’s warranty?                                                           Yes          No
If 'Yes', has a claim been made under the warranty?

  Electrical repairers report

Make of motor 	hp	Serial No.

Voltage	rmp	Open or sealed	Age

Details of damage

Cause of damage

Repair costs - amount	Windings $	Compressor $	Other repairs $ PLEASE ATTACH ACTUAL REPAIR ACCOUNT

Description of goods	
Quantity	
Cost	
Amount claimed	
		$	$	
		$	$	
		$	$	
		$	$	
		$	$	
		$	$	
		$	$	
		$	$	
		$	$	
Repairs having been completed to my satisfaction  I hereby claim the amount of	$	

  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, and that no other persons have an interest of any kind in the said property.

•	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
✗ 	 	      /	/