Claims Notification Form

Section 1 - YOUR DETAILS
Policy Holder's Name *
Address *
Postcode *
Business Occupation *
Day Telephone Number *
Evening Telephone Number
Policy Number *
Are you VAT registered? * yesno

Section 2 - GENERAL DETAILS

Date & Time of Incident *
Address at which loss/damage occurred *
Postcode at which loss/damage occurred *
How did the loss/damage occur? *
Name of persons responsible for loss/damage (if applicable)
Address of persons responsible (if applicable)
Registration of Vehicle (if applicable)

IF PROPERTY WAS LOST, STOLEN, MALICOUSLY DAMAGED OR VANDALISED - PLEASE ANSWER THE FOLLOWING QUESTIONS:

Section 3 - THEFT
How was entry gained to the building?
Were there any visible signs of forced entry to the building?
Date & time incident was reported to the police?
Name & Address of the police station reported to:
Police reference number:
Was an intruder alarm in operation at the timne of incident? yesno
Was the alarm active? yesno

Section 4 - PARTICULARS OF CLAIM

Product Claim 1

Description of Property Lost, Stolen or Damaged
Date of Purchase
Original Purchase Price
Estimated Cost of Repair
Replacement Cost (if not repairable)
Amount Claimed

Product Claim 2
Description of Property Lost, Stolen or Damaged
Date of Purchase
Original Purchase Price
Estimated Cost of Repair
Replacement Cost (if not repairable)
Amount Claimed

Product Claim 3
Description of Property Lost, Stolen or Damaged
Date of Purchase
Original Purchase Price
Estimated Cost of Repair
Replacement Cost (if not repairable)
Amount Claimed

IF YOU HAVE OBTAINED ESTIMATES OR ACCOUNTS, PLEASE ATTACH & SUBMIT THEM.

Document 1

Document 2

Document 3

If water damage, has the source of the leak been rectified? yesno
If the claims is being submitted 30 days after the incident, please advise as to the delay.
Are you the tenant/leaseholder? yesno
If, yes are you responcible, under the terms of your lease, for the damaged claimed for? yesno
Is the property owned by you? yesno
If no, who owns the property?
Is the property fully occupied? yesno
If no, give details

Section 5- DECLARATION
I/We declared that the statements made are true to the best of may/our knowledge & belief & I/we claim the amount above in respect of the terms mentioned. I/We have not witheld from the insurer any information within my/our knowledge connected to this claim.
Agreed * Please sign this declaration by ticking the box.

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