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Details |
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1. Name of Assured: |
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2. Occupation: |
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3. Address: |
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4. Address at which the
loss was sustained: |
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5. Date of Loss: |
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6. Nature of Claim (i.e.
Fire, Theft etc): |
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7. How did the loss or
damage occur? |
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8. (a) Have the Police
been informed and at which Station? |
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(b) Crime Reference Number: |
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9. Does anyone else have
an interest in any of the property? |
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10. Have you any other
existing insurances that refer to the property hereon mentioned? |
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11. (a) Are you registered
as a taxable person for V.A.T? |
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(b) If the answer to (a)
is YES do you obtain full remission of input tax from customs? |
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(c) If the answer to (b)
is NO (i.e. you are Partially Exempt) what percentage are you provisionally assessed
as being able to recover? |
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The issue of this form
is not an admission of liability.
Please also complete the Statement of Claim below
Insurers and their agents share information with each other to prevent fraudulent
claims and for underwriting purposes via the Claims and Underwriting Register, operated
by Insurance Database Services Limited. A list of participants is available on request.
In dealing with your claim we may search the register. In the event of a claim, the
information you supply on this claim form, together with other information relating
to the claim, will be provided to participants. |
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INSTRUCTIONS REGARDING
CLAIM
1. Please submit receipts showing date, price and place of purchase of the articles
set out below and documentary evidence to support the present replacement cost with
this form, whenever possible,.
2. Where property is lost, stolen or totally destroyed, the amounts claimed for these
articles, covered on a new for old basis, should represent the replacement cost of
an equivalent article at the time.
3. In the case of damaged articles, an estimate of repair must be submitted. If the
article is not repairable, please send a letter from the Repairer to this effect.
All salvage MUST be retained.
4. In all other cases, the amount claimed should represent a reasonable figure having
regard to the replacement cost of an equivalent article at the time of the loss, less
an appropriate deduction for wear, tear and depreciation.
5. We may well be able to arrange replacement to save you the trouble of shopping
around. Please give us full details of the item concerned with the Manufacturers Serial
or Model Number if appropriate and we will see if we can do so. |