Burst Geyser Claim Form

Geyser Claim Form

Name:

First

Last

Address:

City

Province

Postal Code

Email Address

Contact No:

Date of Loss:

Time of Loss:

When was loss discovered?

Date

Time

Address where loss/damage occurred or Body Corporate name & unit number:

City

Province

Postal Code

Please indicate any resultant water damage due to burst geyser (if applicable):

Other detail/comments:

Declaration

By clicking here I/We solemnly declare that I/We have suffered loss of or damage to the property enumerated on the reverse hereof and that the said property was in my/our possession immediately prior to the said loss/damage which occurred in the circumstances described above.

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Burst Geyser Claim Form

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