Correspondence Address *

Property Insured Address *

Full Details of Loss *

How Did the Loss or Damage Occur? *

When Was it Discovered? *

The information supplied to us in this form by either you or anyone acting on your behalf will be used by us when dealing with your claim.

Please be aware that if you or your representative makes a claim under your insurance knowing the claim to be false, fraudulent or intentionally exaggerated in any respect, or makes a statement in support of a claim knowing the statement to be false in any respect or submits a document in support of a claim knowing the document to be forged or false in any respect or makes a claim in respect of any loss or damage caused by your wilful act or connivance then your claim will be void and not paid.

I hereby declare that all details provided by me or my representative in this form are to the best of my knowledge and belief true and are a complete and accurate account of the claim I wish to make.