Bankers Indemnity/Fidelity Gurantee Claim Form

Policy No

Insured

Address

Telephone no

E-mail Address

When did the loss occur?

Name of Branch manager/ Head of Dept

Name of Schedule Officer(s)

Name of Culprit(s) if known

How was loss/damage/fraud detected?

Brief account of the loss/damage/fraud

Brief account of the loss/damage/fraud (copy)

Date on which loss/damage /fraud was detected:

If continuous act, give duration of act. From - To

State Amount of Estimated claim

Breakdown of claim amount/ loss

State measures taken to minimize future loss/damage/fraud:

Has incident been reported to the police?

If yes, which police Station

Have you insured with any other company?

If yes, please give name of company

NB: Any other relevant information could be attached below.

File Upload

Click or drag a file to this area to upload.

I/We hereby declare that the above statements are true to the best of my/our knowledge and belief.