property insurance claim form

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:



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:



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:



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:



Declaration

Signor Name:

Signed Date:

Signature: