Miscellaneous Claim Form

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Miscellaneous Claim Form (All lines excluding motor)

NAME OF INSURED(Required)

PHONE NUMBER(Required)

ADDRESS(Required)

FACSIMILE NUMBER(Required)

POLICY NUMBER(Required)

DATE OF LAST PREMIUM PAID(Required)

MM slash DD slash YYYY

Address of premises where loss was sustained(Required)

Date of loss(Required)

MM slash DD slash YYYY

Nature of claim(Required)

Give full details of how loss or damage occurrred(Required)

In cases of loss please give date and time last seen(Required)

MM slash DD slash YYYY

When was loss discovered and by whom(Required)

MM slash DD slash YYYY

Have police been informed (or other enquiries made)?(Required)

Yes

No

To which station was report made:(Required)

Date of report(Required)

MM slash DD slash YYYY

Time of report(Required)

Hours

:

Minutes

Name & address of person who made report(Required)

In the event of damage can article/s be repaired?(Required)

Yes

No

Repairer’s estimate(Required)

Max. file size: 8 MB.

....(Required)

Declaration of property lost or damaged

Where purchased or acquired

Date purchased or acquired

Replacement cost price

% deduction for Depreciation

Net amount being claimed

Remarks (if any)

I DECLARE THAT ALL THE INFORMATION HEREON TO BE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF

DATE(Required)

MM slash DD slash YYYY

A Member Of The Deposit Protection Scheme

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