When completing this form, please ensure all available supporting documentation is attached. When complete, please click the ‘submit’ button.
Policy Number
Policy Schedule Number (if applicable)
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 a: (delete as applicable)
Flat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .
YesNo
Maisonette . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Apartment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
House. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .
Garage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CLAIM DETAILS
Date of incident
Describe what happened, circumstances under which discovered and by whom:
Attach Photographs and Estimates - Word Documents Only (.docx)
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