Engineering Claims Notification Form - Zemen Insurance Company (ZISC)

+251-115 575850 / +251-116 686274 / info@zemeninsurance.com | የስብሰባ ጥሪ

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Engineering Claims Notification Form

Name Of Insured *

Policy no(where branch the policy issued)

Title of contract insured

Name(S) and address of contract site

Name of supervising engineer

When did the loss occur *

What was damaged ? Explanation (Which parts? To what extent?)

Contract Works

Construction Machinery

Construction Plant and Equipment

Add specify work

Add specify work

Add equipment

Driver name *

Plate no(main/trailer)

Phone no *

Licence no

Date

Place

Add details of damage to your machinery

Are there damage occurred to third parties?

Property damage

How did the loss occur and what was the probable cause?

Are there any witnesses to the occurrence of the loss?

YesNo

If so, Please give name, professions and addresses of witnesses.

Are any existing building or surrounding property damaged?

Yes

I, the understand insured declare that I have answered the above questions conscientiously and truthfully.

Date *

Name

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