POLICY & CLAIMANT DETAILS (STEP 1 / 5)

To be completed by the claimant - all fields are required.

Policy number:

Policyholders name:

Insured person's full name:
(Include any titles, e.g Mr / Miss / Mrs / Dr)

Date of birth:

Occupation(s):

Business/Trade:

Address of Property:

Postcode:

Telephone number:

Mobile number:

Email address:
(Claim form confirmation will be sent to this email address)

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LOSS/DAMAGE & PERSON WHO DISCOVERED LOSS (STEP 2 / 5)

Brief Description of Loss:
(We will ask for more details on the next section)

Date of Occurrence?:

Time of Occurrence
(E.g. 4.20pm or 16:20):

Name & Address including postcode of person who discovered loss/damage:

Date lost or damaged property was last seen:

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LOSS/DAMAGE ADDITIONAL DETAILS (STEP 3 / 5)

LOCATION DETAILS

Occupiers Name:

Address:

Postcode:

Telephone / mobile number:

Email address:

DETAILS OF CIRCUMSTANCES

Item damaged:

Peril under which this claim is being made:
(e.g. storm tempest and flood)

Policy section under which this claim is being made:
(e.g. storm damage to farmhouse roof; Section 1 - Private House)

Please describe how the loss/damage was caused:

If fire, please state cause of outbreak

WITNESSES

Are there any witnesses to this loss or occurrence?
-YESNO

If 'YES' to the above - complete witness details below:

• WITNESS 01:

Name:

Address (including area and postcode):

Telephone/Mobile Number:

• WITNESS 02

Name:

Address (including area and postcode):

Telephone/Mobile Number:

IS SOMEONE TO BLAME?

Do you consider anyone to blame or suspect any person of being responsible for this occurrence?
-YESNO

If 'YES' to the above - please give their name and address and state your reasons:

Name:

Address (including area and postcode):

Why do you feel this person is to blame?

REPORTING - LOSS, THEFT, FIRE OR MALICIOUS DAMAGE

To be completed for all claims of loss, theft, fire or malicious damage.

Name of address of police / fire station notified:

Reporting officer’s name and number:

Crime / Fire Reference Number:

If Theft, was there forcible and violent entry to or exit from the premises?
-YESNO

If 'YES' to the above - please give details:

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DETAILS OF PROPERTY LOSS / DAMAGE (STEP 4 / 5)

Full details of property lost or damaged.

ITEM 01

Description of item:
(Include details such as make / model number)

Date of purchase:

Original Purchase Price (£):
(*1 - Upload proof)

Estimated cost of repair/replacement (£):
(*2 - Upload proof)

Amount claimed (£):

ITEM 02 (If applicable)

Description of item:
(Include details such as make / model number)

Date of purchase:

Original Purchase Price (£):
(*1 - Upload proof)

Estimated cost of repair/replacement (£):
(*2 - Upload proof)

Amount claimed (£):

ITEM 03 (If applicable)

Description of item:
(Include details such as make / model number)

Date of purchase:

Original Purchase Price (£):
(*1 - Upload proof)

Estimated cost of repair/replacement (£):
(*2 - Upload proof)

Amount claimed (£):

ITEM 04 (If applicable)

Description of item:
(Include details such as make / model number)

Date of purchase:

Original Purchase Price (£):
(*1 - Upload proof)

Estimated cost of repair/replacement (£):
(*2 - Upload proof)

Amount claimed (£):

ITEM 05 (If applicable)

Description of item:
(Include details such as make / model number)

Date of purchase:

Original Purchase Price (£):
(*1 - Upload proof)

Estimated cost of repair/replacement (£):
(*2 - Upload proof)

Amount claimed (£):

ATTACHMENTS

Note (*1) - Proof of Purchase
Attach/upload original receipt / copy if retained.

Note (*2) - Etimate / Evidence
Attach/upload a current estimate, evidence of replacement article (‘like for like’ basis), or an estimate for repair.

• UPLOAD ATTACHMENT 01:

• UPLOAD ATTACHMENT 02:

• UPLOAD ATTACHMENT 03:

• UPLOAD ATTACHMENT 04:

• UPLOAD ATTACHMENT 05:

• UPLOAD ATTACHMENT 06:

• UPLOAD ATTACHMENT 07:

• UPLOAD ATTACHMENT 08:

• UPLOAD ATTACHMENT 09:

• UPLOAD ATTACHMENT 10:

ADDITIONAL INFORMATION

If you need to add additional information, please use a separate sheet of paper, then take a photo / scan the document and attach it below. Alternatively, you can email any additional documents/files to use once you have submitted your claim form.

NOTES

Please note, if an article is deemed to be beyond repair please attach the written confirmation of this from a professional source. Additionally, please be aware that all supporting documentation is provided at the claimant’s own expense.

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VALUE ADDED TAX & DECLARATION (STEP 5 / 5)

Are you VAT registered?
-YESNO

Can you recover 100% VAT for this claim?
-YESNO

If you answered 'NO' to the above, what percentage (%) can you recover?

PLEASE READ THESE NOTES CAREFULLY AND COMPLETE THE QUESTIONS AS APPROPRIATE:

a.) It may be necessary, to protect your interests, for us to instruct solicitors or other professional people, on your behalf. Where we consider such services necessary we will pay the cost. The services provided attract Value Added Tax.

b.) These services are treated as being supplied to a policyholder and not to their insurers. If you are registered for V.A.T. purposes you will be able to recover V.A.T. or a proportion of it.

c.) If you tell us that you can recover V.A.T. we shall ask the solicitors or other professional person instructed, to send their tax invoice to you when their costs are due. The V.A.T. element should be paid by you and recovered from H.M. Customs and Excise in the usual way.

d.) We shall pay the balance of the account including any proportion of V.A.T. which you cannot recover.

If you are registered for V.A.T, please authorise us to instruct solicitors or other professional people, on your behalf (The V.A.T. content of the account is payable by you to the extent that you can recover the tax.)

-I authoriseNot applicable to me

Insurers pass information to the Claims and Underwriting Exchange Register, run by Insurance Database Services Ltd (IDS) Ltd and the Motor Insurance Anti-Fraud and Theft Register, run by the Association of British Insurers (ABI). The aim is to help us to check information provided and also to prevent fraudulent claims. Under the conditions of your policy, you must tell us about any incident (such as an accident or theft) which may or may not give rise to a claim. We will pass information relating to this incident to the registers.

DECLARATION

You must read the declaration before submitting.

I/We understand that the making of a fraudulent claim by providing untrue information is a criminal offence likely to lead to prosecution.

I/We confirm that the information given on this form is to the best of my knowledge and belief, true in every respect and that I have declared and not claimed amounts refunded to me or claimed from any other source.

Full Name:

Signature:

Date:

Please note: Once you have clicked the submit button, do not refresh the page and please allow a moment for the form to send. A confirmation message will appear once complete. You will also receive a confirmation email with all the details you have submitted.

If an error message appears when submitting, check all information is correct and try submitting again.

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