PROPERTY INSURANCE
DECLARATION OF INTENT TO FILE CLAIM

INSTRUCTIONS

1. Complete the online claim form below.
2. An ALSA agent will contact you for additional information
3. We will send you a completed claim form to sign
4. Your claim will be processed when we receive the signed claim form from you

ALSA Policy Information

Numéro de la police

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Nom

Prénom

Nom de l'entreprise

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Policy holder's address

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Postal Code

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E-mail

Téléphone

INCIDENT DETAILS

Please complete all fields below

Name of Claiming Department

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Name of building concerned

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Address of incident

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Postal Code

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Contact name

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Date and Time of incident

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Description of Incident

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Who discovered the loss?

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Date and time of discovery

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BUILDING INFORMATION

Do you own or lease the building?

We own the building We lease the building

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Date/Year of building construction

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Was the building occupied at the time of the incident?

Yes No

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If not, when was the building last occupied?

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Do any other parties have an interest in the property lost or damanage?

Yes No

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If yes, please explain.

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Was the building fully furnished for occupation at the time of the loss?

Yes No

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Is there any other insurance covering any part of the loss?

Yes No

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Has this building suffered a loss of this nature before?

Yes No

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Was the building undergoing construction or refurbishment work at the time of the incident?

Yes No

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If yes, please provide the name and address of the contractor.

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POLICE, FIRE, AND THIRD-PARTY DETAILS

Were the Police advised of the loss?

Yes No

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If yes, please indicate the date and time the police were notified.

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Name of Police Officer who took the report

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Police Station Address

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Crime Report Number

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Was the Fire Service advised of the loss?

Yes No

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If yes, please indicate the date and time the fire service was notified.

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Name of Fire Official who took the report

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Fire Station Address

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Fire Service Report or Incident Number

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Name of Building Surveyor responsible for repairs & maintenance

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VEHICLE IMPACT

Third Party Vehicle Registration Numbers and contact details

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Third Party Vehicle Insurer details

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COST OF REPAIRS AND REPLACEMENTS

BUILDINGS

Please provide full details of repair/replacement costs. N.B. Coverage is restricted to most economical course of action, be it repair or replacement on a like-for-like basis.

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Please upload a detailed estimate

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CONTENTS

Please summarize items to be replaced.

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Please upload a list of items to be replaced. Include original cost and replacement cost.

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I verified all information, please submit the claim notification

VOTRE PROTECTION EST NOTRE PROFESSION

VOTRE PROTECTION EST NOTRE PROFESSION

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