Start Your Insurance Claim

To start your claim please complete the form below. Alternatively contact us for advice.

    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

    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

    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

    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.

    captcha

    Please insert the code from above before submiting.

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