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Money Claim Form

This document is an insurance claim form requesting details about a money insurance claim, including when and how the loss occurred, prior claims history, and bank account information to process any payout. It notes that full disclosure is required to avoid claim denial and that personal data will be protected according to their privacy policy. Claimants must sign declaring the information is true and return the completed form within 30 days of the loss occurrence.

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123 views3 pages

Money Claim Form

This document is an insurance claim form requesting details about a money insurance claim, including when and how the loss occurred, prior claims history, and bank account information to process any payout. It notes that full disclosure is required to avoid claim denial and that personal data will be protected according to their privacy policy. Claimants must sign declaring the information is true and return the completed form within 30 days of the loss occurrence.

Uploaded by

Hihi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Money Insurance Claim Form

Policy No.:
Claim No.:

You are to disclose to us, fully and faithfully all the facts which you know or ought to know, otherwise the claim submitted hereunder
may be declined.
We are committed to protect the personal data submitted by and collected from you. For further details, please refer to our “Data
Privacy Notice” published in our website.

Name of Insured:
Address:

Tel No.: Tel. No. (H/P):


Occupation: Email:

Is your company GST registered? Yes No

Situation of premises or place where loss occurred:

Date of loss: dd/mm/yy Time: am/pm

Explain fully how the loss occurred:

If the loss was in respect of money while in transit:


How many authorised employees had custody of the money?
How was the money being conveyed (by car, on foot, etc?)

When was the loss discovered? Date: dd/mm/yy Time: am/pm

By whom was the discovery made?

When was the money last seen? Date: dd/mm/yy Time: am/pm

By whom was it last seen?

Have any other steps been taken to recover the money?


(If yes, please give details)
Yes No

Did you make a police report?


(If yes, please give details)
Please answer the following questions if the claim is in respect of a theft at your own premises.
If the loss relates to money in the premise for the payment of salaries, wages or other earnings, when was it received into the premises?
Date: dd/mm/yy Time: am/pm

Do you have a record of the amount of money in the safe at the time of the loss? Yes No

Have you ever sustained a loss or claimed against any Insurer for the risks covered by the policy under which this claim is made?
(If yes, please give particulars)

DATE INSURING COMPANY PLACE OF LOSS AMOUNT (RM)

Are you the sole owner of the lost money? Yes No


(If no, state name(s) of any other interested parties and the nature of their interest)

Was there at the time of the occurrence any other existing insurance, effected by you or any other persons, on the property for which this claim is made?
Yes No
(If yes, please give details)

NO. ITEM INSURED AMOUNT OF LOSS (RM)

Was the safe damaged? Yes No


(If yes, please give make & model and year of model)

Year Purchased: Cost when purchased: Amount of claim:


Name (as per bank account):

NRIC/Passport/Birth Cert. No.: Email:

Bank Account No.:

Name of Bank: Bank SWIFT Code:


Bank Branch/Address:

I/We declare that the particulars given on this from are true and complete.

Signature of employer: Date: dd/mm/yy


(If a limited Company, give status of signatory)

This form should be completed and forwarded to the Company as soon as possible and in no case later than 30 days from the date of the occurrence.
Claimants are advised to read the conditions of the Company’s policies regarding the claims before completing this form.

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