Lost / Stolen / Damaged Equipment

Step 1 of 2

Reference

Incident Type(Required)

Lost Item(s)

Damaged Item(s)

Stolen Item(s)

Have you reported the theft to SAPS?(Required)

Yes, I have a case number

Please note that all incidents of theft must be reported to the relevant authorities. Failure to open a case with SAPS within 24 hours will result in your insurance claim being rejected. You will be responsible for the full replacement cost.

Your Name(Required)

First Last

Email(Required)

Phone(Required)

Company Name(Required)

Incident Details

Date of Incident(Required)

Address of Incident(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Description of Incident(Required)

Please provide as much detail as possible. Failure to provide key information may impact any future insurance claims.

List of Items Damaged / Stolen(Required)

Police Station(Required)

Case Number(Required)

Photo Upload

Drop files here or

Max. file size: 128 MB.

Please upload any photos you feel might be relevant to this submission.

Please Read Carefully

It is herein agreed that the signatory that appears on this form is of the legal age to fully understand and comprehend its contents and all declarations contained herein. In the event that you are claiming you received damaged equipment from us, immediate notification must be sent to us via telephone call, WhatsApp, email or by any provable means. Additionally, this form must be submitted within four hours of said damage discovery. In the event of theft and damage there will be an excess charge payable by yourself/the entity you are representing and you agree and accept full responsibility for the payment thereof. Further, by completing, signing, and submitting this form said signatory is seen as having the full authority to do so, be they acting on behalf of another party on in their own personal capacity. E&OE. All our rights remain reserved.

Signature(Required)