Policy Holder Details Full Name: Policy Reference: Address: Postcode: Telephone: Email: Are you VAT Registered:YesNo What proportion can you recover on the items subject to this claim: Next Circumstances of the incident When was the incident: Who discovered the loss/damage: Location of incident (if different from above) Were there an signs of forced entry to the premises: YesNo How and where was entry made to the premises: You have selected there was Forced Entry to the premises please include all information and details relating to this: How did the incident occur, please include all details including the circumstances and events leading to the incident as you have them as well as information about discovery: Please provide information about who else has information and knowledge of the circumstances of the incident: if you know the person responsible for the damage please give as much details as possible here: Back Next Police Details Address of Police Station: Date and Time Reported to Police: Police / Crime Reference number: General Information Is the property owned by you: YesNo You selected the Property was Not owned by yourself, who is the owner: Was the property occupied at the time of the incident: YesNo You selected the Property was Not occupied, when was it last occupied: Was the property fully furnished at the time of the incident: YesNo Do you hold any other insurance policies which may cover this occurrence: YesNo Insurer Name: Policy Reference: You have selected the you have other insurance which may cover this occurance, please provide details below: Back Next Details of the Claim Details of Items Make & Model number(s) Where Purchased Date Purchased Price Paid Repair/Replacement cost Amount Claimed Any other information you wish to provide in regards to the items listed above: Back Next Declaration Signor Name: Signed Date: Signature: Back
