Claimant Identification Form Male Female Date of Birth Single Married Divorced Widowed Sponsor's Civil ID Number Nationality Present Residence Mailing Address Area Street Block House/Building No. Avenue Apt. No. Area Zip Code P. O. Box Area Street Block House/Building No. Avenue Apt. No. Telephone (Mobile) Telephone (House) Sponsor's Address Area Zip Code P. O. Box Area Street Block House/Building No. Avenue Apt. No. Sponsor's Telephone 1
Transcript
Claimant Identification Form
Male
Female
Date of Birth Single
Married
Divorced
Widowed
Sponsor'sCivil ID Number
Nationality
Present
Residence
Mailing
Address
Area
Street
Block
House/Building No.
Avenue
Apt. No.
Area Zip CodeP. O. Box
Area
Street
Block
House/Building No.
Avenue
Apt. No.
Telephone (Mobile) Telephone (House)
Sponsor's
Address
Area Zip CodeP. O. Box
Area
Street
Block
House/Building No.
Avenue
Apt. No.
Sponsor's Telephone
1
2
Summary of LossesAmount (in K.D)
Dinar Fils
Household Furnishings
Others:
Dinar Fils
Amount (in K.D)
Dinar Fils
K.DTotal Value of Loss on this form (Kuwaiti Dinar)
Total Loss Repaired Total Loss Repaired
Vehicle 1 Vehicle 2
Make
Model/Year
Registration
No.
Vehicl
Identification#
Code of Loss
Original Cost
Value of Loss
3
Property ValueAmount (in K.D)
Dinar Fils
Total Value of Loss on this form (Kuwaiti Dinar)
Type of Property Date PurchasedPercentage of your
ownership
Area Zip CodeP. O. Box
Area
Street
Block
House/Building No.
Avenue
Apt. No.
Floor space of Structure
(Square meters)
Property LossesAmount (in K.D)
Dinar Fils
Total : ( )
4
( ) Less Compensation already received
Summary of LossesAmount (in K.D)
Dinar Fils
Real Property
Any other damages not covered by the above ( )
Net Value of Loss
Amount (in K.D)
Dinar Fils Fils
Official Use
Attach a statement providing details of what happened, a description of damages, and total value
of loss, as well as documentary and other appropriate evidence for each element of such loss.
Summery of Losses Claimed
Have you submitted another claim for the same loss?
