Original purchase receipts or valuations should be attached. Where applicable, attach estimates for repair or replacement, but do not delay submission of this form if not immediately available. Damaged property should be retained for inspection if required.

Detailed Description of Property (including Model & Serial Numbers) Date of Purchase (dd/mm/yyyy) Original Cost Replacement or Repair Cost Amount Claimed £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £

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Insurers share information with each other to prevent fraudulent claims and for underwriting purposes. The information you supply on this form, together with the information you have supplied on the proposal form and other information relating to the claim, may be provided to other Insurers.

The submission of a bogus or exaggerated claim, either in whole or in part, or of any false documentation or statement in support of a claim, may invalidate the whole claim and lead to your policy being declared void.

I declare that the above statements are true and correct to the best of my knowledge and belief

I have not withheld any information within my knowledge connected with this form

I agree to provide the Insurer with any further information or documentation as may be reasonably required

I understand that the Insurer does not admit liability by the issue of this form

I confirm I am authorised to provide information contained in this form

I confirm that I have read and understand the above declaration. *  

Full Name: *		On behalf of: (if applicable)
Date:	11/10/2008	Position:
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