Claim Form – Industry and commerce

Industry and commerce Multi-risk insurance

RadioPolicyholderInsuredLegal representative

Full name

Contact

Form Section

Full name:

Policy number:

Address:

Phone

Form Section

3.1 Type of claimIn case of fireIn case od theftIn case od glass breakagein case of damage caused to third parties (Material/ bodily)

3.2 In case of fire

Were the Firefighters involved?YesNo

If the Firefighters did not intervene, what was the reason?

Was there any suspicion of arson?YesNo

Was the place uninhabited?YesNo

If yes, for how long?

If there are co-owners of the property, please provide their names:

3.2 In case of theft

Authority to which it was reported:

Station/Precinct:

Brigade/Officer:

Case number:

Attach proof of the police report.

3.2 In case of glass breakage

Location where the glass was installed (shop window, door, showcase, etc.):

Glass dimensions

Responsible for the damage (Name and address):

3.2 In case of damages caused to third parties (Material/ bodily)

Name of the Owner/Victim:

Address

Occupation

Marital Status

Age

Relationship?

Witnesses – Name/Address/Occupation?

4. DeclarationThe information provided is accurate, given in good faith and truthfulness, and I take full responsibility for it.I authorize the Insurer to collect complementary personal data from public organizations, specialized companies and other economic units, with a view to confirming or supplementing the information collected that is necessary for the management of the contractual relationship. Omissions, inaccuracies and false statements in providing information are the responsibility of the client. Consultation of the personal data provided will be carried out under a regime of absolute confidentiality, provided it is compatible with the purpose of its collection.