Statement of Claim Form
As the name depicts, a statement of claim form can be used by an individual and by an organization to claim expenses or losses. This statement form can be availed in case of general claims, court claims, insurance claims and travel claims. Statement of claims forms are available for different sections.
Samples Statement of Claim Form:
Date: __________
Personal details:
Name of the claimants: ______________
Date of Birth (MM/ DD/ YY): _________________
Postal Address: ____________________
E-mailer: _________________________________
Residential Number: ________________
Mobile Number: ___________________________
Policy Number (8 digits):______________
Policy date starts from: _______________
Policy end date: __________________________
Description of claim:__________________
Statement of financial condition as of ________, 20_________
for the period ______, ______ to
_________, _________
In what capacity are you making claim: _________________
How the loss did occur?
- Fire breakout
- Accidental reason
- Intentional Cause:
- Not sure
Details of Assets Loss:
- Property Loss:_____________________
Type of property: _________________
- Monetary loss: ____________________
Type of Loss: ____________________
Man Power Loss: ___________________
Others: ___________________________
Net Losses: ______________________
Do you have a FIR copy?
- Yes
- No
Category: Statement Forms
