LOSS OR DAMAGE TO PROPERTY CLAIM FORM

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CLIENT DETAILSPOLICY NO:

ClientName
Address
Postcode
Telephone Number / Fax Number
Trade or Occupation
Are you registered for VAT / YES/NO
If ‘Yes’, please give VAT Registration N°: / Status:
Is the claimant the sole owner of the destroyed or damaged property? / YES/NO
If NO, please give name and address of any person who is financially interested in any of such property and the precise nature of such interest:

CAUSE

Date and time of loss or damage
Address at which loss or damage occurred
State fully the cause of the loss/damage and give full description of circumstances surrounding the loss/damage:
Did the fire brigade attend? / yes/no
Were the Police notified? / YES/NO
If ‘YES’ to either of the above please state station and reference.
Have you ever sustained / a) loss by theft / YES/NO
b) loss or damage by any other cause / YES/NO
If ‘YES’ to either please state particulars below:

BURGLARY OR THEFT

If burglary/theft was from a building, how was entry gained?
Were there any visible signs of a forced entry to the building / yes/no
If ‘YES, provide details:
Was an intruder alarm system in operation at the time of the incident? / YES/NO

PROPERTY

Please give general details of property lost or damaged (give itemised list below):-
Address where property is normally kept.
State number of consecutive days and nights the premises have been left unoccupied prior to loss.
Dwellings only – Were the premises unfurnished at the time of the occurrence? / YES/NO
Have any changes been made in the insured premises since you completed the proposal form for this policy? / yes/no
If ‘YES’ please give details
Please state current replacement value of your contents / £

STATEMENT OF CLAIM

Please note, each article must be separately stated and the value at the date of the damage is to be based on cost price less due allowance for depreciation and wear and tear, unless cover is on a replacement basis.

Invoices supporting purchase and/or a detailed estimate to put the property in the same state of repair as previous to the damage should accompany this form and damaged articles must be retained for the Company’s inspection.

Description of property or article lost or damaged / Date of purchase or acquisition & price paid / Value at time of loss / Value of salvage (if applicable) / Cost of repairs / Net amount claimed

PLEASE ENSURE ALL QUESTIONS HAVE BEEN ANSWERED

IMPORTANT NOTICE

Insurers and their agents share information with each other via the Claims and Underwriting Exchange register, operated by Insurance Database Services Ltd in order to prevent fraudulent claims and to decide whether to accept your proposal and, if so, on what terms. A list of participants is available upon request. The information you supply on this from, together with the information you have supplied on your application form and other information relating to the claims, will be provided to participants.

DECLARATION

I/We hereby declare that these particulars are true to the best of my/our knowledge and the amount stated here and overleaf represents the value of property at the time of the loss or damage. I/We also declare that no other person has an interest in the property whether as Owner, Mortgagee, Trustee or otherwise and that it is not otherwise insured with this or any other policy.

I/We understand that you may seek information from other Insurers to check the answers I/We have provided.

Insured’s Signature: ………………………………… Date: …………………………………..

The issue of this claim form does not constitute an admission of liability.

MPW INSURANCE BROKERS LIMITED

7 / 8 Tolherst Court, Turkey Mill, Ashford Road, Maidstone, Kent, ME14 5SF

Telephone : 01622 683913 / Fax : 01622 690958