Loss Of Money Claim Form - Genesis Insurance Brokers

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PE: 087 701 2222
info@genesisib.co.za
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Electronic Equipment

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Funds Protect

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Motor Traders

Office Contents

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Public Liability

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Body Corporates

Commercial Crime

Contractors All-Risk

Cyber Liability

Directors Liability

Environmental Liability

Erection All-Risks

Events Liability

Fine Arts and Collectibles

Guarantees

Heavy Commercial Vehicles

Hospitality Insurance

Kidnap and Ransom

Marine Insurance

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Medical Malpractice

Plant All-Risks

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Professional Indemnity

Security Liability

Travel Insurance

Wedding Insurance

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Body Corporates

Commercial Crime

Contractors All-Risk

Cyber Liability

Directors Liability

Environmental Liability

Erection All-Risks

Events Liability

Fine Arts and Collectibles

Guarantees

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Hospitality Insurance

Kidnap and Ransom

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Prize Indemnity

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Loss of Money Claim Form

"*" indicates required fields

Name of Insured*

Address*

VAT reg. number*

Policy number*

Due date*

Date of loss*

DD slash MM slash YYYY

Time (e.g. 17:00)*

Name of person conveying cash*

How long has he/she been in your employ?*

Does he/she regularly convey cash*

Yes

No

Please give a detailed statement of the circumstances of the loss*

From and to where was the cash being carried?*

To which police station has the loss been reported?*

Give the name of the investigating officer*

Total amount of cash lost*

State whether treasury notes, cheques, postal orders, money orders, etc

Treasury notes*

Postal and money orders*

Cheques*

Other remittances*

Total amount of cash being conveyed at time of loss*

Do you suspect anyone in connection with the loss*

Yes

No

Details please*

Consent*

i/We warrant that the answers given are true and correct. all details provided on this form are done so honestly and in good faith. This means that The Insurer has been made aware of all important information and that any incorrect information may mean that the claim may be rejected and the policy cancelled*

Signature*

Signature

Capacity*

Capacity

Date*

DD slash MM slash YYYY

Date

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Comments

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Johannesburg Office:

+27 11 789 7845

41 Waterford Office Park, Waterford Drive, Fourways, 2055

+27 11 789 7845
41 Waterford Office Park, Waterford Drive, Fourways, 2055

Cape Town
Office:

Cape Town Office:

+27 21 556 8371

5 Frere Ave, Table View, Cape Town, 7441

+27 21 556 8371
5 Frere Ave, Table View, Cape Town, 7441

Port Elizabeth Office:

+27 87 701 2222

49 Worraker Street, Newton Park, Port Elizabeth, 6001

+27 87 701 2222
49 Worraker Street, Newton Park, Port Elizabeth, 6001

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PE: 087 701 2222
info@genesisib.co.za
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