Seib insurance & Reinsurance Company

PO Box: 10973

Doha-Qatar

MACHINERY BREAKDWON INSURANCE CLAIM FORM

(Issuing this claim form does not constitute an admission of liability on the part of the company)

1 / Name of the insured in full
2 / Address of the insured
3 / Details of the business activity of the plant/factory and number of years of operation.
4 / Policy details / Number:
Period:
Type:
5 / Details of incident:
a)  Day, Date & Time
b)  Cause of loss
c)  Nature of loss
d)  Full address of the plant/factory
e) Whether a supplier / contractor / repairer is responsible either by law or under contract for the subject incident/event?
f) When was the subject item / machinery commissioned to work after successful test?
g) Whether subject incident occurred while the equipment was at work or at rest or during cleaning or overhauling or when being shifted within the premises or during subsequent re- erection? Full details may be provided.
6 / Which items were damaged?
i. ……………………… / [ Which parts & to What extent ]
7 / Estimate of repairs:
i. ………………….. / ( See Annexure for details )
8 / How will the damaged items be repaired/replaced, by whom & where?
9 / Is recovery possible from Third Party? If yes, have you lodged a claim? Please give full particulars. Name & address etc.
10 / Whether you are the sole owner of the items/ machinery damaged?
11 / Attach incident report on the sequence of happenings signed by authorized signatory.
12 / Any witness to the incident/event? If so, please attach witness statement.
13 / Give details of previous instances when a similar loss had occurred involving the same items/machinery/plant/factory.
14 / Any recovery achieved? (Through police / direct). If any, please give details thereof.
15 / Are there any other insurances against the subject risk upon the same machinery? If so, give full particulars.
16 / Improvements in the system proposed/effected to avoid such recurrence.

Declaration:

1.  I/We the above named being insured under the above policy do hereby declare and set forth that an incident/event occurred at the above described plant/factory/workshop in the manner stated and the items/machinery enumerated in the list attached and valued at sum of ______were damaged/destroyed.

2.  I/We do further declare that no other person has any interest in the said items/machinery, whether as owners, mortgagee, trustee or otherwise, and that it not otherwise insured against the described risk(s), with this or any other office, except as above stated.

3.  I/We do further declare that to best of my/our knowledge & belief that the foregoing particulars are true & correct.

Signature of the Insured Date:

Name: Stamp: