CELL PHONE CLAIM FORM

							                     CELL PHONE CLAIM FORM.
GENERAL INFORMATION:
NAME OF INSURED:                                 _______________________________________________________
IDENTITY NUMBER:                                 _______________________________________________________
TELEPHONE NUMBER [W]:                            _______________________________________________________
TELEPHONE NUMBER [H]:                            _______________________________________________________
ADDRESS:                                         _______________________________________________________
                                                 _______________________________________________________
                                                 _______________________________________________________
                                                 _______________________________________________________
OCCUPATION:                                      _______________________________________________________

CELLULAR TELEPHONE DETAILS:
MODEL:                                           _______________________________________________________
SERIAL / EMI NUMBER:                             _______________________________________________________
DATE OF PURCHASE:                                _______________________________________________________
CONTRACT WITH;
[VODACOM / MTN / CELL C/ VIRGIN]                 _______________________________________________________

CELL NUMBER:                                     _______________________________________________________

DESCRIPTION:
WHERE DID LOSS OCCURR:               _______________________________________________________
DATE OF LOSS:                        _______________________________________________________
TIME OF LOSS:                        _______________________________________________________
DESCRIBE FULLY HOW THE LOSS OCCURRED: _____________________________________________________
                                     _______________________________________________________
                                     _______________________________________________________
                                     _______________________________________________________
                                     _______________________________________________________
HAS THE PHONE BEEN BLACKLISTED:      ______________________________________________
DETAILS OF HIE PURCHASE [IF ANY]:    ______________________________________________
WAS THE LOSS REPORTED TO THE POLICE: _______________________________________________________
IF NOT REPORTED WHAT WAS THE REASON:_______________________________________________________
POLICE REFERENCE NUMBER:             _______________________________________________________
HAVE YOU REPLACED THE PHONE:         _______________________________________________________
AMOUNT CLAIMED:                      _______________________________________________________
ARE YOU THE SOLE OWNER:              _______________________________________________________

NB: PLEASE NOTE THAT, SHOULD THE PHONE BE IRREPARABLE, INSURERS WILL REQUIRE THE
SALVAGE BEFORE THE CLAIM CAN BE SETTLED.


I / We guarantee that the information as set out above is true and declare no information has been withheld.

Signed at:……………………………………..on……………………………………20…….


Signature of Insured:____________________________________________