Property Claim Form

Policy Number
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First Name
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Surname
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Address
Please enter your addres

Postcode

Phone
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Email Address
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Occupation
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VAT Registered
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Date
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Where did the loss/damage occur?
Please describe

Describe fully how loss/damage occured?
Please describe

In the event of theft, was the alarm activated?
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Were the police notified?
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If yes, address of station?
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Date of notification to police
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Police Crime Reference Number
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Were the Fire Brigade called?
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If yes, address of station?
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Was any person responsible for loss/damage? If yes, say why.
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Name of person responsible
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Address of person responsible
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Pease State Insurer's Name
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If they are insured against causing this incident

Insurer's Address*
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Policy Number*
Please type your policy number

State Insurers Name, Address and Policy Number
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If they are insured against causing this incident

Type of Premises?*
Please enter the type of premises

Were the premises unoccupied?
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Are you the owner of the premises? *
Please select an option

If yes, when last occupied?
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If no, please give name and address of owner
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Are you responsible for repairs?
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Is there any other policy in force providing cover for this incident?
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If yes, please give details to include Insurers name, adress and policy number
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What is the total of buildings/contents?
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What is the total of stock/plant and machinery on the premises?
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Have you ever suffered similar loss/damage? If yes, please give details
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List/Description of Contents Destroyed/Damaged
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Extent of Damage
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Owner of Articles/Property
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Date of Purchase
Please enter a date

Cost Price
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Replacement Cost
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Value at the time of damage
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Allowing for wear and tear where applicable

Salvage value?
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(Value if any after claim)

Sum Claimed
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