Company Reg. No. : 192300014M

20 McCallum Street#09-01 Tokio Marine Centre
Singapore 069046
Tel : (65) 6221 6111 Fax : (65) 6225 9887
Email : tmis@tokiomarine.com.sg
Website : www.tokiomarine.com.sg

Burglary Claim Form
The issue of this form is not to be taken as an admission of liability by the Insurers.
Fire & GA Claims Dept, Fax : 6225 9887
This claim form should be completed and returned within seven (7) days of its receipt by the INSURED
Name of Policyholder :Policy No :Tel No :Address:

Email :
Contact Person :Address of the Premises at which the loss occurred:
On what date and time were your premises broken into?

@ about

am / pm

On what date and hour was the robbery discovered?

@ about

am / pm

Robbery was discovered by

Designation of this person:

Which rooms were ruffled? :Describe means by which entry was obtained and state what doors or windows were forced open?

Were the premises occupied at the time? If not, upon what date and at what hour were they last occupied?
Any suspect? If so, state the name :Are you the sole owner of the property stolen/damaged? ()Yes()NoAre there any other insurance against theft upon the same property? ()Yes

If No, state name of owner.
()No If Yes, please specify:

What was the value of the total contents at your premises at the time of the loss? $Have you ever before sustained loss by fire, burglary, housebreaking or larceny? ()Yes()No

If Yes, please provide history of previous claim/s made (include name, date, nature of loss & amount paid):

Please state the total amount claimed next page. Give a detailed list (with separate value of each article or item) of the property
lost and attach a copy of the police report. Please attach additional listing if space provided is insufficient.
Declaration : I/We hereby declare that these particulars are true to the best of my/our knowledge and belief and I/we have in nomanner caused the loss nor by any fraud or misrepresentation sought to benefit thereby. I accept that insurers would be atliberty to deny liability in part or in full if the above written answers are false or inaccurate in any aspect.
Notice for Personal Data Protection Policy
By signing this form:i) I/We acknowledge and consent to TMiS collecting, using, processing and disclosing to third party service providers and/orintermediaries, within or outside Singapore, my/our personal data for the purpose of processing and servicing my/ourpolicies/claims;ii) I/We declare and confirm that I/we have obtained the consent of the person(s) and/or nominee(s) named herein, whereapplicable, and that he/she/they has/have authorized me/us to disclose their personal data and to give consent on their behalf
for the above collection, use, process and disclosure; andiii) I/We acknowledge the detailed Privacy Policy Statement, governing the above, posted at www.tokiomarine.com.sg.
Signature & Company Stamp :Name :

Date :NRIC:

Designation:

Details of Amount ClaimedA) If claim is for repairable damage, give particulars of damage and a tradesman’s estimate for the repairs.
B) If claim if for non repairable damage on loss, list items below completing all columns. Supporting estimates f or replacement may behelpful.
Specifications of property
Lost / destroyed

Cost Price

Where bought &Date Purchased

Value at time of loss

Please attach additional listing if space provided is insufficient.
Please mail duly completed claim form to: Tokio Marine Insurance Singapore Ltd, 20 McCallum Street #09-01, Tokio Marine Centre, S’pore 069046.
Fire & GA Claims Dept, Fax : 6225 9887.

2