AT LLOYD by benbenzhou

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									 PRESTIGE UNDERWRITING SERVICES
              LTD.
                                                CLAIMS REPORT FORM

    Please answer the following questions as fully as possible and return to: Prestige Claims Department,
                       Lanyon Building, 5th +6th Floor, North Derby Street, Belfast, BT 15 3HL



POLICYHOLDER DETAILS

Policy number:                                                 Claim Ref:



Name of Insured:                                               Date of Birth:

Address (inc postcode):

Email Address:                                                 Occupation:

Daytime Telephone Number:

When & Where Can You Be Interviewed Regarding the Loss:



Are you registered for V.A.T.?....YES/NO                    If “YES” please state V.A.T. reg.no;

LOSS DETAILS

Date of occurrence:                                         Where did loss/damage occur?



Nature or Cause of claim (Fire, Theft, Storm, etc)

Describe how loss/damage occurred:




If known, state name & address of person causing the damage:



If Theft, was entry or exit forced?



Is there any other Insurance in force in respect of this loss or damage? If “yes” please give details



Are you the sole owner of the property for which you are claiming?       If “no” please give details



If a tenant, are you legally liable under an agreement for decorations and other repairs to the buildings?

Have you made any previous claims under a Householders policy of Insurance?

If “yes” Please give details.

                                                                                                             p.t.o.

                                                                                                                      1
Details of property lost or damaged this time.
1)     Receipts or valuations of original property should be supplied in support of your claim.
2)    Estimates to replace lost/damaged property to the nearest equivalent should be supplied.
3)    If property is repairable at least two estimates should be obtained.
Please complete the following;
      Description of property including: .make/model etc                                                   Purchase date / pric e                                   Amount of claim

                                                                                                                                                       cost of repair or replacement




Sharing Information: Insurers share information with each other to prevent fraudulent claims and for Underwriting
purposes. The information you provide on this form and your proposal form and other information relating to the claim may
be disclosed to other Insurers.
I hereby declare that all the details given on this form are to the best of my knowledge true and complete




 Date........................................................................Signed................. .........................................................................................




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NOTIFICATION TO THE GARDA SIOCHANA


This section must be completed if claiming for theft, accidental loss, vandalism or malicious damage.
To be completed with the Garda Siochana.




This is to certify that                             of

reported to this station on        /       /20      the **theft/loss/damage to

                                                                                                on       /        /20     .

We have made a note of the interest of Prestige Underwriting Services in our records and shall contact them if any property is
recovered or if anyone is made amenable.

Signed (Garda):

Station Address:



Contact Number:
Please stamp this form




**Delete as appropriate




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