All Risks Claim Form FOR ALL RISK, FIRE, MONEY, HOUSEHOLDERS, HOUSEOWNERS, BURGLARY, COMBINED, SPECIAL PERILS BROKER/AGENCY POLICY NO CLAIM NO 1. THE INSURED Title First Name Surname ID Number Bank Account No. Address Street Address Address Line 2 City State / Province / Region Occupation or business Telephone No. Home Business Email Address* Address at which the loss or damage occurred When did the loss or damage occur? Date Describe fully how the loss or damage occurred Have you previously suffered a loss? Yes No Full description of previous claims/losses Were the premises occupied at the time of loss or damage? If not, when was it last occupied How were the premises occupied at the time of loss or damage? Was the loss or damage reported to the Police? If not, why? If so, when and where Z. R. Police reference No Are you the sole owner of the lost or damage? If not give full particulars of other parties concerned Is there a bond on the property? What is your estimate value of the building(s) at the time of loss or damage? $ What is your estimate value of the entire contents at the time of loss or damage? $ Has the building(s) has a thatch roof? Is the lost or damaged property insured under any other policy? If so, give full particulars I/We warrant the truth of the answer to the above questions and I/We declare that no information has been withheld and that the amount claimed represents my/our loss arising from the above stated occurrence. THE ISSUE OF THIS FORM IS NOT AN ADMISSION OF LIABILITY I hereby certify that the information in this claim form is true and correct to the best of my knowledge and belief. I authorize Champions Insurance Company to process the claim based on the information provided.