CLAIMS – Takaful

Please give definite and complete answers to each question. The issue and acceptance of this form should not be regarded as an admission of liability.
Policy Number
Name of Insured*
First Middle Last
Email
Enter Email Confirm Email
Phone Number*
Town
P.O. Box
Post Code
Date of Damage
Date Format: MM slash DD slash YYYY
Time of Damage

: HH

MM
Cause of Damage
Date of Damage
Date Format: MM slash DD slash YYYY
Time of Damage

: HH

MM
Brief Description
Have Police been notified, if so, when? What are the results of police investigation, if any?
Police Notification outcome
Are you insured for the present loss under any other policy?
- Yes
- No
Consent*
I/We hereby declare the foregoing particulars to be true to the best of my/our knowledge and belief.