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Policy Number
Policyholder:
Name of Claimant
Property Address:
Correspondence address (If different from above)
Contact Number
Contact email:
State the nature of your interest in the property being claimed for, i.e Owner, tenant
   
Is the dwelling: (delete as applicable)  
a. a Flat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . Yes No 
b. a Maisonette . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 
c. an Apartment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 
d. a House. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . Yes No 
e. a Garage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 
   
CLAIM DETAILS   
Date of incident
Describe what happened, circumstances under which discovered and by whom:
Attach Photographs and Estimates - Word Documents Only (.docx)