The Business Insurance Bureau

Property Claim Form

Please complete this form to intimate a Property Claim.

    Policy Holder Details

    Full Name:

    Policy Reference:





    Are you VAT Registered: YesNo

    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:


    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:

    Police Details

    Address of Police Station:

    Date and Time Reported to Police:

    Police / Crime Reference number:

    General Information

    Is the property owned by you:


    You selected the Property was Not owned by yourself, who is the owner:

    Was the property occupied at the time of the incident:


    You selected the Property was Not occupied, when was it last occupied:

    Was the property fully furnished at the time of the incident:


    Do you hold any other insurance policies which may cover this occurrence:


    Insurer Name:

    Policy Reference:

    You have selected the you have other insurance which may cover this occurance, please provide details below:

    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:


    Signor Name:

    Signed Date: