Home Contents Claim Form
The acceptance of this Form is NOT an admission of liability on the part of HL Assurance Pte. Ltd.. Any documentary proof or report required
by HL Assurance Pte. Ltd. shall be furnished at the expense of the Policyholder or Claimant.
A. PARTICULARS OF POLICYHOLDER / INSURED
Name & Address Policy No. Period of Insurance
Tel No. (Office) Tel No. (Residence/H/P)
E-mail (Office) E-mail (Personal)
Is your company GST registered? Date of Birth
Business/Occupation
Nationality
UEN/GST Registration No. (if any)
NRIC/Passport No.
Gender Male Female
B. DETAILS OF THE INCIDENT / LOSS
Description of the Incident / Loss
Country: Singapore Malaysia Others: ____________________________
Place of Incident / Loss
Date of Incident / Loss Time of Incident / Loss
When and Who discovered the Incident / Relationship to Policyholder
Loss
Name & Address of any witnesses of the NRIC/Passport No.
Incident / Loss
Contact No.
C. POLICE REPORT
Please Note:
1) The Police must be informed immediately if the property has been lost or maliciously damaged.
2) To enclose a copy of the Police Report / Statement
Were particulars of loss or particulars If yes, please specify Name of Police Station:
taken by or reported to the Police
Yes No
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D. DETAILS OF PROPERTY DESTROYED OR DAMAGED
Please note:
1) Property damaged, lost or stolen is to be described in detail.
2) Invoices / Receipts showing date, price, and place of purchase of the articles set out below should accompany this form.
3) The insured must promptly take all possible steps to trace/recover the property lost.
4) In the case of damaged property, an estimate for repair should be submitted. If the property is not repairable, a letter from
repairers to that effect should be forwarded. All salvage must be retained.
5) A set of photograph depicting the damage is to be submitted to us.
DESCRIPTION OF PROPERTY QUANTITY ORIGINAL PURCHASE VALUE AT DEDUCTION AMOUNT TO BE
LOST OR DAMAGED PURCHASE DATE TIME OF FOR VALUE CLAIMED
(Please use supplementary sheet if PRICE LOSS AFTER OF
necessary) DEDUCTION SALVAGE
FOR WEAR
AND TEAR
TOTAL AMOUNT CLAIMED
Did you remove or save any property If yes, how much and where is it located now?
immediately before or during the occurrence?
Yes No
Are you the sole owner of the property/article If no, please state name, address & relationship.
lost or damaged?
Yes No
E. LEGAL LIABILITY
1. DETAILS OF ALL PERSONS INJURED (Please use supplementary sheet if necessary)
NAME/ADDRESS/CONTACT NO. OF NATURE OF INJURIES/REMARKS AGE RELATIONSHIP OCCUPATION
PERSON INJURED
2. DETAILS OF PROPERTIES DAMAGED (Please use supplementary sheet if necessary)
NAME/ADDRESS/CONTACT NO. NAME & EXTENT OF APPROXIMATE ESTIMATED COST OF RELATIONSHIP
OF OWNER OF THE PROPERTY PROPERTY DAMAGED VALUE OF REPAIRS TO VERIFY
DAMAGED PROPERTY THE PROPERTY
DAMAGED DAMAGED
Has any claim been made upon you? If yes, please state details & attach with this form all communications received from third party
claimant(s):
Yes No
Have you admitted responsibility in any way? If yes, please state the reason(s) for doing so.
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F. OTHERS (Please specify details of any claim other than Sections D & E)
DETAILS OF CLAIM (Please use supplementary sheet if necessary) AMOUNT TO BE CLAIMED
G. ANY OTHER INSURANCES
Are there any other Policies of insurance in force covering you in respect of this event? Yes No
If yes, please specify below:
INSURANCE CO & POLICY NO(S) POLICY PERIOD KIND OF COVERAGE COMPENSATION AMOUNT
(Please use supplementary sheet if necessary)
H. CLAIMS HISTORY (Please use supplementary sheet if necessary)
Have you or any insured person previously sustained loss/damage or caused damage/injury to third parties? Yes No
If yes, please specify below:
NAME OF INSURER CLAIM NO. DATE OF LOSS NATURE OF LOSS AMOUNT PAID
(Please use supplementary sheet if necessary)
*I/We do solemnly and sincerely declare that the information given is true and correct to the best of my/our knowledge and belief. *I/We
understand that any false or fraudulent statements or any attempt to suppress or conceal any material facts shall render the Policy void and we
shall forfeit our rights to claim under the Policy.
Name of Policyholder/Insured ____________________________ Signature of Policyholder/Insured ____________________________
(Please affix company stamp if applicable)
Date ___________________
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