Home › Claims Notification Form Start Your Insurance Claim To start your claim please complete the form below. Alternatively contact us for advice. Contact Us 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. Please insert the code from above before submiting.