CLAIM FORM

Please complete all details on this document in BLOCK CAPITALS.

Insured’s Name:


                                                                            Post Code
Policy Number:

Daytime Contact Telephone No(s):

Date of Incident:                   Time:                Date Discovered:               Time:

Place of Incident:

How and by whom discovered:

Give FULL details in the box below of exactly how the loss, destruction or damage occurred. Please include
a note of any action taken by you to mitigate the loss, destruction or damage. If you consider that a third
party is responsible for the loss, destruction or damage, you should include a note of the reasons why and
his/her name and address.

1.   If lost, stolen or maliciously damaged:
     (a) Full address of Police Station to which notice was

     (b) Time and date reported:

     (c) Police Reference/Crime Report Number:

     (d) Name of Officer dealing:

2. If incident occurred abroad, please advise dates of travel and attach documentation in support:
3.    Are you the sole owner of the property lost, destroyed or damaged?                  Yes           No
      If No, please give details:
4.    Is the property insured elsewhere? (e.g. Travel, Golfers policy etc)                Yes           No
      If Yes, please give details including policy number and name of insurer:

5.    Have you ever suffered any previous losses of this nature?                          Yes           No
      If Yes, please give full details below:

Details of Lost, Destroyed or Damaged Property
     Full Description of Property          Where & when         Original Cost       Current          Amount of
                                        originally purchased                         Value            Claim

                                                                       Total Amount              £
1. For claims involving riot or civil commotion, you should return this claim form duly completed
    immediately, so that insurers receive it within seven days of the loss or damage.
2. For all other claims, you should return this claim form duly completed as soon as possible so that
    insurers receive it within 30 days of the loss or damage.
3. You must not authorise repairs to be carried out without the insurer’s prior approval.
4. You will normally be required to provide at least two estimates for repair or replacement.
5. When returning this claim form, please enclose original purchase receipts or other evidence of purchase
    for all lost or damaged items.

I, the above named insured, declare that these particulars are true to the best of my knowledge and belief. I
understand that if any part of this claim is found to be fraudulent in any respect, all benefits under the policy
will be forfeited and I may be liable to prosecution.

Signature: _______________________________                                   Date: ________________________

        Registered in England No 1014026 Registered Office 14 Fenchurch Avenue London EC3M 5AT

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