ALAL

Fire Insurance Claim Form

CLAIM FOR LOSS BY FIRE UNDER POLICY No:...........................................................................

I/We............................................................................................................................................................
of................................................................................................
Being insured under the above mentioned policy, do hereby declare and set for that
at about ................................oclock, on ..........................the................................
day of .........................20.............. a fire occurred in.................................................................................
.......................................................................................................................
occasioned, to the best of ........................... Knowledge and belief, by................
.......................................................................................................................................
And I/We further declare taht the property mentioned on the other side, insured under the policy of
.........................................................................................................................
was destroyed or damaged by the said fire to the extent of the amounts there specified.
I/we also further declare that........................................................................
of the property above referred to, and that it is not otherwise insured with
........................................................................ or with any other Company, except as mentioned below.

Witness my/our hand this................................day of..................................20..........

Signature of Claimant.........................................................
Statement of the insurance in force upon the property destroyed or damaged by fire.
......................................In the ............................... Insurance Co. By Policy No................................
......................................In the ............................... Insurance Co. By Policy No................................
......................................In the ............................... Insurance Co. By Policy No................................

ALAL

STATEMENT OF CLAIM
Qty.

Description of the property destroyed or

damaged Particulars to be given in detail

Price

Value at time of fire

Value of Salvage

Amount Claimed