Claims Form

Full name

Date of birth

Email Address

Correspondence Address

Preferred Contact Number

Company Name (If Commercial/Group Policy)

Policy Number

Relation to Policy (if Commercial/Group Policy - e.g. Tenant, Employee)

Claim Type Claim TypeAccidental DamageCommercial - GeneralEscape of waterFireFloodLegalLiabilityLossMalicious DamageMedicalMotor - GeneralMotor - Third PartyOtherPetProperty WorksTheftTravelUnsure

Incident Date

Circumstances