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ANY IMMEDIATELY) Name and Address 2 Policy No. 3 Date of Loss/Accident 4 Description of Loss or Damage 5 Cause of Loss or Damage 6 Downloaded from www.insureatclick.com-Broker : Loyal Insurance Brokers Ltd. 1 If by Theft a) Time and Day b) How Committed c) By whom discovered and when d) Have Police been notified, If so, when e) State result of Policy Investigation, if any 7 Are you insured against the present loss Under any other Policy I declare that foregoing statement are true.

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