Page 19 - Personal Underwriting Mandates & Guidelines - Binder product rules & addendums - Version 1

General Procedures
Annexure A
PRELIMINARY CLAIMS ADVICE FORM Agent company :
Number of coupon/policy : Nominated agent claim number : Name of Insured : Insured's postal address :
Contact person (where the insured is a Co.) : Insured's reference : Insured's bank details :
Sasria deduc ble/Co-insured applicable
If YES, state amount/percentage : Period of insurance :
Ra ng classi ca on : Es mate of claim : Date of loss : Address at which loss occurred :
Brief descrip on of loss :
Name of Loss Adjusters : If appointed and date of appointment : Broker's name : Broker's address :
Broker's contact person : Broker's claim number : Agent's contact person : Date submi ed :
Signed by (name in block le ers) :
11. UNDERINSURANCE AND CONTRIBUTION
Where the Insured has not adequately insured himself, we will apply average in the event of a claim, as he is deemed to be his own Insurer for the balance of the loss propor onately. Average will be calculated as follows:
: YES NO
Sum Insured X adjusted loss Value of risk 1
= claim – excess
= amount payable
Binder Claims Mandates and Guidelines – 2015/2016 Page | 17