GOODS IN TRANSIT INSURANCE CLAIM FORM by oae20205

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									                                        GUARANTY TRUST ASSURANCE PLC
                                  Plot 928A, Bishop Aboyade Cole Street, Victoria Island, Lagos.
                                                     Tel: 234-01-2701560 - 5

                              GOODS IN TRANSIT INSURANCE CLAIM FORM
                     THE COMPANY DOES NOT ADMIT LIABILITY BY THE ISSUE OF THIS FORM

Name:______________________________________________________ Policy No:___________________________

Address:_________________________________________ Date of payment of last premium____________________

Business or Occupation: ______________________________________ Telephone No__________________________
1.   Please give the following information about the claim:
     (a) When did it happen? At____________________ a.m./p.m. On:______________________________________

     (b) Where did it happen?:_______________________________________________________________________

     (c) How did it happen?:________________________________________________________________________

         ________________________________________________________________________________________

         ________________________________________________________________________________________


     (d) Description of goods concerned_______________________________________________________________

     (e) Delivery Way Bill No_______________________________________________________________________

     (f) Total value of goods________________________________________________________________________

     (g) How were goods packed? ___________________________________________________________________

     (h) Name/Address of Driver_____________________________________________________________________

     (i) Address from which goods were dispatched_____________________________________________________

     (j) Name and address of consignees______________________________________________________________


2.   If another vehicle was involved, name and address of owners___________________________________________

        _________________________________________________________________________________________

3.   If insured, name of Insurance Co__________________________________________________________________

4.   Name and address of witness_____________________________________________________________________

        _________________________________________________________________________________________



5.   (a) Have you informed the police?_____________ (b) If so, by whom and when and at what police station? _____


      ___________________________________________________________________________________________
                                      PARTICULARS OF GOODS LOST OR DAMAGED


Quantity                              Description                                                             Value




                                   Please continue description overleaf if necessary


Address where damaged goods can be inspected._________________________________________________________
IF YOU ARE THE OWNER OF THE GOODS, PLEASE COMPLETE THIS SECTION
How and by whom were the goods transported?__________________________________________________________
________________________________________________________________________________________________
Have you advised them of the loss or damaged? _______________________________________Date advised________
Name and address of their Insurers____________________________________________________________________
________________________________________________________________________________________________
IF YOU ARE CLAIMING AS CARRIER OF THE GOODS, PLEASE COMPLETE THIS SECTION
Name and address of owners of goods_________________________________________________________________
Name and address of their Insurers____________________________________________________________________
________________________________________________________________________________________________
Were you the principal contractor, or a sub-contractor?____________________________________________________
Registered letter and number of your vehicle concerned___________________________________________________
If your vehicle was unattended when loss or damage occurred, how was it secured?_____________________________
________________________________________________________________________________________________
Were the goods in sound condition when received?____________________________________Were they checked by your
driver?______________________________________________________________________________________
Did you or your employees load or unload the vehicle?____________________________________________________
Did the consignee accept delivery? ____________________________________if so was a receipt given? ___________
Has a claim being made against you by the owner? _______________________________Date received ____________


I/We declare that the foregoing answers are true and complete.



Date:______________________________________                                            Signature:__________________________

								
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