Insurance Claim Form (Page 2 of 2) in pdf

Do any other insurance in force cover the property?

Yes

If yes please state Insurers name: ___________________________________________________________

Address: _______________________________________________________________________________

Policy No: ______________________________________________________________________________

Estimated Cost of Repairs: £ ________________

Amount Claimed: £____________________________

Details of repair/replacement: _______________________________________________________________

_______________________________________________________________________________________

Note:

Claims for Loss or Damage under £1,000 can be submitted with one invoice. Claims over £1,000 should

be supported by two comparative tradesmen or builders estimates, which can be forwarded later if not available

immediately. The original invoices and receipts for any work already carried out should also be forwarded.

Has the Loss Adjuster already been advised of the claim and authorised the work?

Yes

In respect of this claim will the Insured or lessee/tenant be able to recover VAT on the cost of repair or

replacement?

Yes

If yes - Insured or Lessee/Tenant: ________________________

(If YES the recoverable element of VAT should be deducted from the amount claimed)

Please specify to whom any settlement cheques should be made payable?

Owner/Managing Agent:

_______________________________________

Other (please Specify):

_______________________________________

Declaration:

I/We declare that the information given on this form is true to the best of my/our knowledge and

belief.

Signature: ________________________________________ Date: ________________________

Countersignature: __________________________________ Date: ________________________

(Owner/Managing Agent)

This form should be sent to your nominated Account Handler at the Loss Adjuster, with full supporting documentation.

This should include one estimate/invoice if under £1,000, two estimates if over. You should also provide any

photographic evidence or witness details to substantiate the claim.

VRS Vericlaim UK Ltd

Suite 306

1Alie Street

London

E1 8DE

Insert Client Name here – Claims Procedure 2005/6

Insurance Claim Form Page 2