Insurance Claim Form

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CLAIM FORM
Policyholder: ______________________________________
Policy No: _____________________
Contact name: ______________________________
Contact Number: ________________________
Tenant/Lessee:
Mr/Mrs/Miss
Forename: ___________________Surname:_______________
Address where injury/damage occurred: ___________________________________ ___________________
_______________________________________________________________________________________
____________________________________________________________Postcode:___________________
Time and date of loss: _________ am/pm on: _______/_______/________
Circumstances and cause of loss and extent of damage:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
If the claim is for water damage please confirm the cause has been rectified?
Yes
No
At the time of the incident were the premises:
Occupied
Unoccupied
Let
Unlet
Type of premises:
Commercial
Residential
Block of Flats
Police Crime Reference No for theft and Malicious damage claims: __________________________________
Address of Police Station:
________________________________________________________________________________________
________________________________________________________________________________________
Station name & address of Fire Brigade if they attended:
________________________________________________________________________________________
________________________________________________________________________________________
Who is responsible under the lease for these repairs? Insured or Lessee/Tenant: ______________________
Are there any other persons interested in the property?
Yes
No
If Yes state name______________________ and Interest__________________________________________
Insert Client Name here – Claims Procedure 2005/6

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