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    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.

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    • © 2021 Glowsure Limited
    Glowsure is a trade mark of Glowsure Limited | Glowsure Insurance Brokers is a trading name of Glowsure Limited which is authorised and regulated by the Financial Conduct Authority. Registered in England no 08548780. Registered address: 17c South Lane, Clanfield, Hampshire, PO8 0RB.
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