The Business Insurance Bureau

Making it cheaper by doing it right since 1983

    Policy Holder Details

    Full Name:

    Policy Reference:

    Address:

    Postcode:

    Telephone:

    Email:

    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:

    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: