CLAIMS Form PROPERTY v1 Eng tcm1914 388026

							Chartis Vietnam Insurance Company Limited
Ground Floor, Rosana buiding, 60 Nguyen Dinh Chieu, District 1, HCMC, Vietnam
Tel: 848 3910 4488 | Fax: 848 3824 6758 | Email: vninfo@chartisinsurance.com



                                                 CLAIM FORM – PROPERTY DAMAGE
Important:
1. The insured is requested to furnish the particulars as fully and accurately as possible and to return this form
immediately to Chartis Vietnam.
2. The acceptance of this form is not in itself an admission of liability on the part of Chartis Vietnam.

POLICYHOLDER/INSURED INFORMATION:
Full Name: ...................................................................................... Policy Number: .........................................................
Address ………………………………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………………………………..
Occupation/Business ……………………………………………………………………………………………………………………………………………………
Tel: ................................... Fax: ................................ Email: ..............................................................................................
Mobile: ...................................
Please check this box if you would like to opt out of receiving notifications regarding your claim via SMS?

PARTICULARS OF OCCURRENCE
Time and Date: ……................................................................................Place: ...................................................................
Description of Events : ……..................................................................................................................................................
………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………

DETAILS OF LOSS AND DAMAGE TO INSURED PROPERTY

When was the loss or damage discovered and by Whom? …………………………………………………………………………………..

    Description of Articles/                              When was it             Price paid              Cost of                   Claimed                          Remark
    Property damaged/lost                                 purchased                                       repair/                   amount
  *(Please submit purchase invoice)                                                                       replacement




 Are you the sole owner of the property/article lost or damaged?                                                Yes        No
 If No, please state name, address, contact no and relationship …………………………………………………………………………….
 ………………………………………………………………………………………………………………………………………………………………… …………...
 Is there any other insurance upon the same property/article?                                            No         Yes
 If Yes, please state: Name of Insurance Co. ………………………………………………………………………………………………………………
 Policy No. …………………………………………………………..Type of policy …………………………………………………………..…………….
 Are there any eye witnesses?                        No        Yes
 If Yes, please state names, address and contact numbers …………………………………………………………………………………….
VNM_EN_FORM_CLM_PROPERTY v 1.0                                       www.chartisinsurance.com.vn                                                                        Page 1
Chartis Vietnam Insurance Company Limited
Ground Floor, Rosana buiding, 60 Nguyen Dinh Chieu, District 1, HCMC, Vietnam
Tel: 848 3910 4488 | Fax: 848 3824 6758 | Email: vninfo@chartisinsurance.com



 ………………………………………………………………………………………………………………………………………………………………………………
 …………………………………………………………………………………………………………………………………………………………………… …………
Name of Police Station/Post the incident was reported ……………………………………………………………….…………………………….




Amount Claimed                              BANK TRANSFER INFORMATION (Please transfer settlement to my bank account)
                                            Name:                   ……………………………………………………………………...
                                            Account number ( VND) : ………………………………………………………………….…..
                                            Bank name       :      .………………………………………………………………….…..
                                            Bank IFS Code   :     ………………………………………………………………….…….
                                            Bank address    :     ………………………………………………………………….…….

CLAIMANT AUTHORISATION
l/We declare that I/we have complied with the conditions and warranties (if any) of the policy and in no manner
deliberately caused the said loss or damage or sought unjustly to benefit thereby by any fraud or willful
misrepresentation and that the information shown on this form is true and that I/we have not concealed any
information relating to this claim.




Name and signature of claimant                                            Company Stamp, if applicable




VNM_EN_FORM_CLM_PROPERTY v 1.0                        www.chartisinsurance.com.vn                                Page 2