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 (Inc. any titles):

Date of birth:

Occupation(s):

Address:

Postcode:

Telephone number:

Mobile number:

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

BACKNEXT STEP

ACCIDENT / LOSS DETAILS (STEP 2 / 5)

Date of loss or damage?:

Time of loss or damage?:
(Example 4.20pm OR 16:20)

Where did it occur?:
(Address and nature of premises)

Please give a full description of the accident / incident:

BACKNEXT STEP

THIRD PARTY INJURY / EMPLOYEE INJURY (STEP 3 / 5)

Full name of third party:

Telephone number:

Address (including area and postcode):

Is the injured party an employee?
-YESNO
• If 'YES' to the above - complete the details below.
• If 'NO' to the above - skip to the next step.

Full name of employee:

National insurance number:

Address (including area and postcode):

Date of birth:

Marital status:

Is the employee under your direct employment?
-YESNO
At the time of injury, was the employee at work under your employment?
-YESNO
Occupation:

Length of service:

Has the employee returned to full time work?
-YESNO
If so, what was the date of their return to work?:

Give details of employees NET weekly wage (£):

Or, NET monthly salary (£):

Give details of weekly statutory sick page / company sick pay (£):

BACKNEXT STEP

INJURY / DAMAGE (STEP 4 / 5)

What is the nature of the injury or damage?

ATTACHMENTS - SUPPORTYING EVIDENCE

Attach any supporting documents/images of the damaged item(s) / replacement value:

Document upload 01:

Document upload 02:

Document upload 03:

Describe the documents you have attached (e.g evidence of injury, location etc). If you are unable to supply any supporting/requested documents/images, please explain why this is, to enable us to help you more quickly:

WITNESSES (IF APPLICABLE)

WITNESS 01:

Name:

Address (including area and postcode):

Telephone/Mobile Number:

WITNESS 02

Name:

Address (including area and postcode):

Telephone/Mobile Number:

ANY LETTER OR DOCUMENT YOU RECEIVE SHOULD BE PASSED TO US IMMEDIATELY AND UNANSWERED.

BACKNEXT STEP

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

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.

BACK