The undersigned Name/Surname
Residence address:
proprietor (proprietor representative
)
of the buildings/goods
, from the premises
, facultative insured with policy no.
,
acknowledge the insured event:
burglary/robbery,
fire,
natural perils ,
other causes
occurred in
,
hour
The event was notified to:
police station
fire brigade
other institution authorized to investigate the occurred event
from
which issued the following documents:
The event took place in the following circumstances:
Thé losses consist in:
Responsible for the damages occurred is
, with residence in
In order to evaluate the losses please contact:
phone:
The undersigned, declare on my own responsibility that
the statements from this Notification are real and accurate.
