FIRE CLAIM FORM

POLICY NO. VALID UPTO: CLAIM NO.

Name of Insured
Trade or Occupation
Address

When did the Fire take place?

The Fire take place 16-Apr-2023 in Sahiwal zone.
Situation of Property damaged or destroyed
Some lights and UPS Burned All others things saved .

How were the premises occupied at date of

We approached the UPS and tried to unplug and dismantle the batteries but unfortunately the UPS
Fire?
burned
What was the cause of the Fire, and under
fluctuation in voltage
what circumstances did it occur?

Does the policy give a correct description of

the property in all respects as it existed
immediately before the Fire?

Has any element of risk been introduced which

was not allowed by the policy?
Have the conditions of the Policy been
complied with in every respect?
Is the Claimant the sole owner of the property
damaged or destroyed? If not, state full
particulars of any other interest.
Has there been a previous Fire in these
premises, or in any other premises in which
the Insured was interested? If so, state full
particulars, including the cause,
of such Fire or Fires.
Give full particulars of any existing NAME OF COMPANY AMOUNT
Insurances on the said property at the
time of with any other Company or
Society. If not, please write "No
Company or Society. If so, state full
particulars .

I/We of do hereby
declare that the abvoe is a full, true and acurate statement, and I / we further declare that the Articles mentioned on the other side,
being my / our property, and insured under the abvoe-named policy or policies, were accidentally destroyed or damaged, without any
design or procurement on my / our part, by the aforesaid Fire/Peril according to the extent and values annexed; wherefore I/we claim from the
sum of Rs. the value thereof.

As witness my hand, this day of Year

Signature of Claimant
 INSTRUCTION TO BE OBSERVED IN MAKING OUT A CLAIM

(1) Where possible claim should be accompained by Builders, Architect or Repairer's estimate.
(2) A Fire Policy being a contract of Indemnity only, not profile of any kind should be included in the amount
claimed where in at the time of the loss. Contemplated improvements must not be included.
(3) (a) Claim in respect of Buildings should be based upon the cost of restoring them to the condition they where in
at the time of the loss. Contemplated improvements must not be include.
(b) Claims for the Furniture, fittings, Machinery, Tools, Electrical Appliances, etc must not exceed their value
at the time of the loss: that is after due allowance has been made for age, wear and tear and depreciation during
the time of they have been in use. Where appropriate, the claim will be based on the cost of repairs or of
restoration.
(c) Claim of Stock-in trade should be based on values at the time of the loss after deduction of all
discounts or allowances. Due allowance must be made for out of date and unsaleable stock.

NOTE:- This Form must be filled up and delivered to the company within FIFTEEN DAYS
from the date of the fire Before filling it up. The claimants is requested to read the condition of
the Company's Policy/ies in regard to claims.

DETAILED STATEMENT OF PROPERTY DESTROYED OR DAMAGED

Value at time of the Amount Claimed i.e.
loss after allowing for actual loss after
Amount of Salvage
Policy No. Description of the Articles age; wear & tear and deduction of Salvage
depreciation Value
Rs. Ps. Rs. Ps. Rs. Ps.

I/We now residing at

do hereby declare that the above is a full, true and accurate
statement, and I/We further declare that the Articles mentioned herein being my/our property and insured under the above named Policy
or Policies were accidentally destroyed or damaged without any design or procurement on my/our part by the aforesaid Loss, according to
the extent and values annexed : Whereof I/We claim from Century Insurance Company Limited the sum of Rs. the amount thereof.

I/We solemnly declare that I/We have no manner nor by any fraud nor wilful misrepresentation nor non-disclosure sought unjustly to
benefit by the said fire and that this solemn declaration made by me/us conscientiously believing the same to be true.

As witness my/our hand, this ......................................................... day of ....................................20........

Signature of Claimant .......................................................

(Insured)