Corporate And Commercial Claim Form - Vero
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1
2Corporate & Commercial claim form
Please help us to help you by:
•
completing all relevant questions in full as this can avoid the need for further enquiry and possible delay in settling your claim
•
enclosing evidence of the amount(s) you are claiming
•
signing and dating the reverse side of this form
Insurance fraud is a crime - please ensure all information is correct.
1.
Policyholder(s) details
Policy number
Claim number
(if known)
Full name
(Mr, Mrs, Miss, Ms)
/
/
Date of birth
Postal address
Home
Business
Mobile
Telephone numbers
Home
Business
Email
Contact Person
2.
Details of claim (complete in all cases)
/
/
Time of fire, accident or loss
am/pm
Date of fire, accident or loss
Location where loss or incident occured
a.
Please state full details of what
happened
b.
Is the property owner/occupied,
rented or let to tenants? Please
specify which one.
c.
Is there insurance with any other
company relating to this loss? If so,
please give details.
d.
If loss was caused by another
person who is not your employee,
please give their name, address,
and telephone number.
YES
NO
e.
Have you made any other insurance claims over the past 5 years?
If Yes, please give details
3.
Glass breakage
If you are the tenant of commercial premises please provide proof that you are liable under the terms of your lease.
Particulars of Glass Damaged:
Description (plain, plate, mirrored, etc.)
Height
Width
Position (door, window, etc)
4.
Police details (if burglary, theft, loss or malicious damage)
a) To which police station was it reported?
b) Date reported
/
/
YES
NO
c) Attach police form
d) Police file number
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Parent category: Legal