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Fire and/or theft car insurance claim form
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IMPORTANT: PLEASE TICK THIS BOX IF IT IS YOUR INTENTION TO CLAIM UNDER THE UNINSURED LOSS RECOVERY SECTION OF THIS POLICY.
Zurich policy number
Broker reference number
Zurich claim number
Important notes to be read before completing this form
1. Please fill in ALL RELEVANT SECTIONS OF THE FORM. A fully completed form will help us to deal with your claim more efficiently.
2. The form should be completed in BLOCK CAPITALS.
3. If you need more space to answer any of the questions, please use a separate sheet and ATTACH it to this form.
4. Please submit original documents in support of your claim as copies are not acceptable.
5. Zurich Insurance Company does not admit liability by issuing this form.
6. If the insured vehicle has been damaged beyond economical repair, WE WILL MOVE THE VEHICLE TO A PLACE OF FREE STORAGE PENDING
RESOLUTION OF YOUR CLAIM unless you wish to make other arrangements. (If you wish to make alternative arrangements, please tell us
immediately.) Please ensure your personal effects are removed from the vehicle.
Warning – Fraud
The information supplied to us by you may be held on computer and passed to other insurers for underwriting and claims purposes.
Under the conditions of your policy you must tell us about any Insurance related incidents (such as fire, water damage, theft or an accident) whether or not
they give rise to a claim. When you tell us about an incident we will pass information relating to it to a database. We may search these databases when you
apply for insurance, in the event of any incident or claim, or at time of renewal to validate your claims history or that of any other person or property likely to
be involved in the policy or claim.
In order to prevent and detect fraud we may at any time: – Share information about you with other organisations and public bodies including the Police;
Check and/or file your details with fraud prevention agencies and databases, and if you give us false or inaccurate information and we suspect fraud, we will
record this. We and other organisations may also search these agencies and databases to: – Help make decisions about the provision and administration of
insurance, credit and related services for you and members of your household; Trace debtors or beneficiaries, recover debt, prevent fraud and to manage your
accounts or insurance policies; Check your identity to prevent money laundering, unless you furnish us with other satisfactory proof of identity; Undertake
credit searches and additional fraud searches. We can supply on request further details of the databases we access or contribute to.
Details of policyholder
Name
Postal address
Town County Post code
Home telephone number (inc. STD) Business telephone number (inc. STD) Mobile telephone number
Occupation (including any part-time work)
Please tick box
Are you able to recover VAT on repairs to your vehicle? Yes No
If Yes, but you are partially exempt, what percentage are you provisionally assessed as being able to recover? %
Details of policyholder (continued) Please tick box
Type of UK driving licence held Full Provisional None
Date UK driving test passed Date of birth
Have you any conviction in connection with any motor vehicle or are any charges pending? Yes No
If Yes, give full details including dates
Details of insured vehicle
Make Model Colour
Registration number Cubic capacity Year of make
Are you the owner? Yes No If No, are you the registered keeper? Yes No
If NO, to either, advise details of the owner/registered keeper
Is the vehicle subject to a Hire Purchase agreement? Yes No
If Yes, state name, address, telephone number and account number of Finance Company
Please indicate the price
On what date did you purchase the vehicle? Was it purchased new? Yes No £
paid for the vehicle
Mileage at date of fire/theft?
What was the general condition of your vehicle at time of fire/theft?
Was there any pre-fire/theft damage or rust on body work? Yes No
If Yes, give details
Were there any special features about the vehicle such as conversions and/or additional equipment? Yes No
If Yes, give details
Damage to insured vehicle
HAVE YOU CONTACTED THE ZURICARE HELPLINE FOR ASSISTANCE? Yes No
Repairer’s name and address
Town County Post code
Repairer’s telephone number (inc. STD) Please tick box
Is the vehicle still in use? Yes No
If No, indicate address where it can be inspected
Town County Post code
Where your vehicle is damaged and you are entitled to claim under your policy please supply an estimate for the repairs unless you have elected for the
repairs to be undertaken by a Zurich Insurance Quality Assured repairer.
Use of insured vehicle
For what purpose was the vehicle being used at the time of the fire or prior to the theft?
Social/Domestic Home to work/Work to home Business Other
If Business or Other, give particulars including details of any goods being carried
Driver or last person in charge
Were you driving/last in charge of the vehicle? Yes No
If Yes, you need not complete the next section, if No, the next section MUST be completed in respect of the person who was driving/last in charge.
Details of person last in charge (if not policyholder)
Name
Postal address
Town County Post code
Home telephone number (inc. STD) Business telephone number (inc. STD)
Mobile telephone number
Occupation (including any part-time work)
Is he/she employed by you? Yes No
Type of UK driving licence held Full Provisional None
Date UK driving test passed Date of birth
Has he/she had any conviction in connection with any motor vehicle or are any charges pending? Yes No
If Yes, give full details including dates
Was he/she using the vehicle with your permission? Yes No
Has he/she a vehicle of his/her own? Yes No
If Yes, give name of insurer and policy number
Details of incident
Fire claims only
Date Time Location of fire (street, town)
am/pm
State cause of fire
Address of attending fire brigade
Town County Post code
Theft claims only
Was your vehicle stolen? Yes No
Where did the theft take place? (street, town)
State date and time vehicle last seen Date Time
State date and time theft discovered Date Time
Has your vehicle been recovered? Yes No
If Yes, where from?
Was vehicle garaged prior to the theft? Yes No If Yes, was the garage locked? Yes No
Were all doors and windows in the vehicle secured? Yes No
Theft claims only (continued) Please tick box
Were the ignition keys stolen with the vehicle? Yes No
If yes, please state where the keys were within the vehicle
Were any anti-theft devices fitted and used at the time of theft? Yes No
If Yes, provide details
State full address of Police Station where theft reported and Crime Ref. if known
Town County Post code
Details of contents stolen or damaged
Value at time of
Description of item Purchase price Date of purchase theft or fire Time reported to police
£ £
£ £
£ £
£ £
£ £
Details of any other insurers of damaged or stolen property
Were these items in a locked boot/glove compartment? Yes No
Documents required
Please supply with this form items 1 and 2 in all cases, items 3 to 9 should also be supplied where vehicle not recovered or if damaged beyond economic
repair. If the documents are not available you should obtain duplicates. If you are unable to do so please explain why and provide the additional
information requested. The provision of these details will assist in the valuation of your vehicle and early settlement.
1. Your driving licence and driving licence of person last in charge of vehicle.
2. Notification of Loss Report Form issued by Police.
3. Registration document.
4. MOT certificate (where applicable) – if unavailable, indicate date of test and address of testing garage and obtain duplicate copy.
5. Vehicle keys with spare set – if no spare set available please advise when last in your possession.
6. Purchase receipt for vehicle – if unavailable, indicate date vehicle purchased, amount paid and name and address of person from whom you purchased the vehicle.
7. Vehicle service records or documents.
8. Recent photographs of the vehicle in it’s pre-accident condition if available.
9. Hire purchased or Leasing Agreement.
Please also supply any other information or documents which you feel will assist in the valuation of your vehicle.
NOTIFY US IMMEDIATELY IF THE VEHICLE IS RECOVERED BEFORE OR AFTER SETTLEMENT.
Circumstances of the fire or theft
State fully what happened
Declaration
If your Policy is in joint names but you do not have a joint Bank Account, please indicate to whom any settlement cheque should be made payable
I/We declare all these particulars to be true and understand that you may seek information from other insurers to check the answers I/We have provided.
Policyholder’s Signature Date
PL6/4946.08 (2/06)
Zurich Insurance Company Personal Insurances, Zurich House, PO Box 310, Stanhope Road, Portsmouth, Hampshire PO1 1ZP
Switchboard: 023 9282 2200 Fax: 023 9282 3772 www.zurich.co.uk/personal
Zurich Insurance Company. UK Head Office: Zurich House, Stanhope Road, Portsmouth, Hampshire PO1 1DU. A limited company incorporated in Switzerland. Registered in the Canton of Zurich. Number CH-020.3.929.583-0.
UK Branch registered in England. Number BR105. Authorised and regulated by the Financial Services Authority. These details can be checked on the FSA's register by visiting their website www.fsa.gov.uk/register or by
contacting them on 0845 606 1234.
