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AUTOMOBILE PROOF OF LOSS

This form is provided to comply with the Insurance Act,
and without prejudice to the liability of the Insurer

IBC CLAIM FORM NO.2

Claim No …. [insert_php] echo ” “.$_REQUEST[‘c’].” “;[/insert_php]
AGENT/BROKER …. [insert_php] echo ” “.$_REQUEST[‘b’].” “;[/insert_php] …………………………………………
INSURER …. [insert_php] echo ” “.$_REQUEST[‘i’].” “;[/insert_php] ……………………………………………………..
INSURED …. [insert_php] echo ” “.$_REQUEST[‘n’].” “;[/insert_php] ……………………………………………………..