Multi Purpose	Client No.
	TOWER	Claim Form	Agency No.
	Insurance

DATE OF LOSS, DAMAGE OR OCCURRENCE:

TIME:

PLACE, AND/OR PREMISES WHERE IT OCCURRED:   PLEASE STATE FULL PARTICULARS HOW LOSS, DAMAGE, OR ACCIDENT OCCURRED, WHEN DISCOVERED, NATURE OF DAMAGE OR INJURY:   PLEASE INDICATE NAME AND ADDRESS OF PERSON RESPONSIBLE FOR DAMAGE:   ARE YOU THE OWNER OF THE PROPERTY LOST OR DAMAGED? (YES/NO) IF NOT, PLEASE STATE PARTICULARS:   DO YOU HOLD ANY OTHER INSURANCE UNDER WHICH A CLAIM FOR THIS LOSS, DAMAGE, OR ACCIDENT MAY BE MADE? (YES/NO) IF SO PLEASE STATE FULL DETAILS:

DESCRIPTION OF PROPERTY LOST OR DAMAGED (PLEASE STATE EACH ARTICLE SEPERATELY)	DATE PURCHASED	PRESENT COST OF REPLACEMENT	DEPRECIATION FOR AGE AND CONDITION	VALUE OF SALVAGE (IF ANY)	AMOUNT OF CLAIM
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COMPLETE WHERE APPLICABLE

FOR ALL RISKS, BURGLARY, AND THEFT CLAIMS 1. HAVE POLICE BEEN INFORMED OF THE LOSS? (YES/NO) POLICE STATION REPORTED TO: 2. REPORTED BY DATE: 3. HAS LOSS BEEN REPORTED IN NEWSPAPER? (YES/NO) PLEASE ATTACH NEWSPAPER CUTTING)

FOR BREAKAGE OF GLASS CLAIMS 1. HAVE YOU ARRANGED REPLACEMENT AND IF SO BY WHOM? 2. DO YOU REQUIRE US TO SETTLE THE GLAZIER'S ACCOUNT OR MAKE PAYMENT TO YOU?

FOR PUBLIC LIABILITY CLAIMS 1. NAME AND ADDRESS OF PERSON INJURED, OR OWNER OF PROPERTY DAMAGED 2. WAS PERSON INJURED, OR OWNER OF PROPERTY DAMAGEDIN YOUR SERVICES, OR IN THE SERVICE OF ANY CONTRACTOR OR SUB-CONTRACTOR? 3. HAS A CLAIM BEEN MADE UPON YOU? (YES/NO) IF YES PLEASE STATE DETAILS, AND ATTACH ANY RELEVANT PAPERS 4. NAME AND ADDRESS OF WITNESSES OF ACCIDENT (N.B. THIS INFORMATION IS OF THE UTMOST IMPORTANCE) 5. NAME OF INSURER OF ANY PROPERTY DAMAGED: NOTE: THE INSURED SHOULD NOT ADMIT LIABILITY OR ADVISE HE IS INSURED.

FOR STORM CLAIMS 1. DID THE STORM CAUSE DAMAGE TO THE BUILDING? 2. IF YES GIVE BRIEF DETAILS

FOR TRAVELLERS CLAIMS 1. IF BAGGAGE LOST, HAS THE LOSS BEEN REPORTED TO THE POLICE, STEAMSHIP COMPANY, AIRLINE, RAILWAY, OR OTHER CARRIER? (YES/NO) IF SO WHERE AND WITH WHAT RESULT (ATTACH ANY CORRESPONDENCE) 2. DETAILS OTHER STEPS TAKEN TO RECOVER THE ARTICLES: 3. TOTAL VALUE OF ALL BAGGAGE AT THE TIME OF THE LOSS: IF CLAIMING UNDER ANY OTHER SECTION OF THE POLICY PLEASE SUPPLY FULL EXPLANATION AND MEDICAL CERTIFICATES IF APPLICABLE

PLEASE SIGN DISCHARGE AND DECLARATION A. I/We agree to accept payment of K   and/or COST OF REPAIRS in full settlement of all my/our claims under the policy for this loss. B. I HEREBY DECLARE THAT I have in no manner caused the said loss or by fraud or willful misrepresentation sought unjustly to benefit hereby, AND I make solemn Declaration conscientiously believing the same to be true and by virtue of the provision of   rendering persons making a false declaration for willful and corrupt perjery. TAKEN & DECLARED AT   THIS DAY OF        IN THE YEAR

BEFORE ME COMMISSIONER FOR OATHS

INSURED