ALL OTHER CLAIMS

First, tell us who is claiming.

Use details exactly as they appear on your policy documents.

Name of insured Address Telephone number Email address Policy number Existing claim number

iNo claim number yet? GoldStar can assign one after first notification.

Claim type

Which claim type applies?

ALL OTHER CLAIMS

Build a clear picture of what happened.

Facts and full answers help the claims team assess your loss efficiently.

Date of incident Time of incident Premises or place where damage occurred How were the premises or property being used? Cause of damage and full sequence of events

Does the property claimed belong to you?

Yes, I am the owner No, another party owns it

Is there other insurance on this property?

No other insurance Yes, another policy exists

Driver details

Driver's full name Date of birth Driver's address Driving permit number Telephone number

Accident details

Date of accident Time of accident Place of accident Road surface Visibility Weather Road wet or dry? Police station reported to Driver's full statement

Accident plan

Upload a clear sketch showing roads, vehicle positions, directions and point of impact.

01 Plan or sketch Image or PDF

Driver's digital signature

Driver signs here Use mouse, stylus or finger

Statement by owner or insured

Owner or insured's full statement

ALL OTHER CLAIMS

Itemise what was lost or damaged.

Add one row per item. Values should reflect market value at time of loss, excluding profit.

Currency

TOTAL AMOUNT CLAIMED UGX 0

Amount and certification

Total amount of loss (UGX) Total amount of loss (USD) Full details of how the amount was calculated Certified by accountants or auditors? Previous loss or suspicion involving these employees?

Money withheld from employees

Has any money due to the employees been withheld?

Other guarantee or security

Do you hold another guarantee or security for the employees?

Insured vehicle damage

Apparent damage to the insured vehicle Repairer's name Repairer's telephone Repairer's address Is the vehicle still in use? Inspection place and time

Other vehicle involved

Registration number Name of insurer Name and address of driver

Details of other property damaged

Other property damaged

Persons injured

Name and address Relationship to the insured If driver or passenger, registration number of the vehicle Apparent injuries

Independent witness

Name Address

Passengers in your vehicle

Name Address

Motor claim evidence

Attach available documents now. The claims team may request originals or further evidence.

01 Police documents Police report or notice 02 Repair estimate Garage or assessor quote 03 Photos and evidence Vehicle and scene photos

Supporting Documents

Please submit all relevant documents at your disposal. If it is not available at this moment, submit the claim anyway and our team will get in contact with you.

Required and optional documents are mapped from Pramel's claim-document matrix for the selected route.

ALL OTHER CLAIMS

One final check before signing.

Confirm key details, then accept declarations from the All Other Claims form.

CLAIM TYPE All Other Claims

INSURED & POLICY Not provided Policy number not provided

INCIDENT Not provided Location not provided

LOSS & DOCUMENTS 1 item UGX 0 total claimed · 0 files attached

Declaration

I declare that details provided are a full, true and correct statement of insurance in force and loss sustained. Amounts claimed for property damaged or destroyed represent market value at time of loss and exclude profit of any kind.

I confirm this declaration * I understand false or incomplete information may affect this claim.

Data privacy and protection

I consent to GoldStar Insurance Company Ltd disclosing, sharing, storing or processing data provided by me, my officers, directors, employees, agents or affiliates with contracted or affiliated third parties, only for purposes limited to or related to this claim.

I consent to claim-related data processing * Required to assess and administer the claim.

Digital signature

Sign here Use your mouse, stylus or finger

Your signature is stored only with this draft on this device.

Designation Witness name Date signed

Important note from the claim formIssue or completion of this form does not imply admission of liability by GoldStar Insurance Company Ltd. Answer every question fully; ticks and dashes are not accepted as substitutes for details.

What do you need to claim for?

First, tell us who is claiming.

Build a clear picture of what happened.

Itemise what was lost or damaged.

One final check before signing.

Declaration

Data privacy and protection

Your claim has been submitted.