Fidelity Shield: Claim Form

Claim Notification Form

All sections are required.

INSURED:
TEL NO:
FAX NO:
E-MAIL:
POLICY NO:
DATE OF LOSS/ACCIDENT:
BRIEF CIRCUMSTANCES OF LOSS/ACCIDENT:
ACTION TAKEN:	e.g. to prevent futher loss, notification of police
REPORTED BY:

to

~Products~ ~Branches & Contacts~
~About Us~ ~History~ ~Reinsurance Arrangement~ ~Organisational Structure ~
~Claims~ ~Enquiry Form~

FIDELITY SHIELD INSURANCE COMPANY LIMITED

SERVICE STRENGTH INTEGRITY
®2001