I understand that I am fully bound by my conscience in making this statement and that any misrepresentation of the facts constitutes fraud. I have no other insurance on the property claimed for above. I hereby agree that the Insurers of the Policy may take over and conduct this prosecution for their own benefit of any claim for cover or otherwise and shall have full discretion in the conduct thereof.

(Please complete a separate form for each item being claimed.)

I/We hereby declare that all the information declared above is true in every respect and that I/We have not withheld any relevant information and I/We will assist with any additional information that is required to finalise this claim.
I/We hereby authorise Adminplus/the Insurer to carry out any checks required to validate my/our claim including but not limited to ITC checks, Beacon and Billings information, last Usage, CCTV footage and SAPS information.
I understand that I am fully bound by my conscience in making this statement and any misrepresentation of the facts constitutes fraud. I have no other insurance on the property claimed for above.
I hereby agree that the insurers of the policy may takeover and conduct any prosecution for their own benefit of any claim cover or otherwise and shall have full discretion in the conduct thereof.