NOTIFICATION OF LOSS OR DAMAGE FOR MACHINERY BREAKDOWN INSURANCE* To: Date: ‘Thru; TOTAL CLAIMS SPECIALIST, INC. Policy No.: Claim No.: Name and address of insured: ‘Work Address: ‘Name of Chief Engineer: Nearest Railway Station: QUESTIONS ANSWERS 1, When did the loss or damage occur? (Status date and exact time) 2. Give name and address of witnesses to the occurrence: 3. Which items were damaged? a) Item number in Schedule of ‘Machinery; b) Sum insured; ©) Description of damaged item: (Capacity, number of revolutions, ‘weight, etc.) d) Name of manufacturer, type of machine; ¢) Year of manufacture, serial ‘number; (full details as on amaker’s plate to be given) 4, Which parts were damaged? 5. How did the damage occur and what ‘was its probable cause? (Please attach sketches, photos, otc.) ‘¥7 The issue of this form is not to be taken as an admission of liability by the Insurer.6. Give name and address of witnesses 10 the occurrence: ‘How will the damaged items be repaired? 8. Will any alternations or improvements ‘be made to design, constraction or ‘material when repairs are carried out? 9. What are the estimated costs for the Tepair of damaged to: a. Equipment b. Machinery 10. Is Third Party Liability involved? 11. Are existing buildings or surrounding property damaged? 12, Remarks ‘The Undersigned Insured declares to have answered the above questions conscientiously and truthfully. Dated. this day of. 20 Signature Printed NameNON-WAIVER AGREEMENT KNOW ALL MEN BY THESE PRESENTS: Itis hereby mutually understood and agreed by and between represented by this agreement by hereinafter called the claimant, and the msurance ‘Companies represented by Adjusters, TOTAL CLAIMS SPECIALIST, INC. ‘That any action akon bythe companies or thei representatives in investigating the clin modo y the claimant for his loss which occurred on, orin the mvestgtion cr sscrnmen ofthe amount of ect ca val a Tos, dal not waive or invalidate any condition of the policies of such companies held by said claimant, nor the right of either or any of the parties to this agreement, and such action shall not be, or be claimed to be, an admission of liability on the part of said companies, or any of thera. ‘The consideration of and for this agreement, is the mutual desire and intention of the parties hereto, to determine the value of the property and/or the amount of the damage thereto without regard to any other questions, Insured Location Property involved in Claims Date of loss Witness our hands this day of. 20___inthe Philippines. TOTAL CLAIMS SPECIALIST, INC. By: Claimant ‘Adjuster