Property/Fire 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.
PARTICULARS OF POLICYHOLDER / INSURED
Name Insurance Policy No. Period of Insurance
Tel No. H/P No.
E-mail Name of Intermediary (if any)
Address NRIC/Passport No. Business / Occupation
Is your company GST registered? UEN/GST Registration No. (if any)
DETAILS OF LOSS OR OCCURRENCE
Nature of loss / damage (e.g. Fire / Water Damage / Burglary Country of occurrence: Singapore Malaysia Others: ____________
/ Plate Glass / Machinery Breakdown / Errors & Omissions)
Place of loss or occurrence
State name and address of the person responsible for the loss / damage
Explain fully how did the loss / damage occur Date of loss Time of loss
On when and by whom was the loss Relationship to Policyholder
discovered
Name & Address of any witnesses of the NRIC/Passport No.
Incident
Contact No.
ADDITIONAL DETAILS FOR GLASS BREAKAGE CLAIMS
Dimensions of broken glass
Type of glass
Situation (e.g. Window, door, showcase etc.)
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POLICE REPORT
Were particulars of loss or particulars If yes, (a) Please specify name of Police Station:
taken by or reported to the Police?
Yes No
(b) Attach a copy Police Report/Statement.
N.B. The Police must be informed immediately if the property has been lost or maliciously damaged.
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. A set of colour photographs depicting the damage and/or CCTV footage showing circumstances of incident are to be submitted to us.
4. Police Report and/or Incident Report are to be submitted to us.
5. Assessment report from the repairer on the cause and extent of the damaged property is to be submitted to us.
6. At least 2 quotations for repair / replacement of the lost or damaged property are to be submitted to us. If the property is not repairable, a
letter from repairers to that effect should be forwarded. All salvage must be retained.
7. The insured must promptly take all possible steps to trace/recover the property lost and in the case of theft to discover and punish the
guilty party / parties.
8. Policyholder/Insured has a duty to take immediate action to mitigate loss by taking necessary measures to minimize and present further
loss or damage.
DESCRIPTION OF PROPERTY LOST QUANTITY ORIGINAL WHERE VALUE AT TIME DEDUCTION AMOUNT
OR DAMAGED PURCHASE AND OF LOSS AFTER FOR VALUE TO BE
PRICE WHEN DEDUCTION FOR OF CLAIMED
BOUGHT WEAR AND TEAR SALVAGE
(Please use supplementary sheet if necessary)
TOTAL
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
DETAILS OF THIRD PARTY (IF ANY)
Name of Third Party Brief Description of Nature & Extent of Damage / Injury
Address of Third Party Comments (if any)
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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 SUM INSURED
CLAIMS HISTORY
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 ___________________
Ver 1.1
