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.

Description of Property Date of Purchase Original Cost Approximate Replacement or Repair Cost £ £ Add Another  £ £ Add Another  £ £ Add Another  £ £ Add Another  £ £ Add Another  £ £ Add Another  £ £ Add Another  £ £ Add Another  £ £ Add Another  £ £

You may upload an attachment related to this claim:
Click the 'Browse' button to locate the file on your PC you wish to attach to your claim

Insurers pass information to the Claims and Underwriting Exchange register, run by Insurance Database Services Ltd (IDS Ltd). The aim is to help us to check information provided and also to prevent fraudulent claims. When you tell us about an incident which may or may not give rise to a claim, we will pass the information relating to it to the register. In assessing claims made insurers may also undertake checks against publicly available information as necessary such as electoral roll, county court judgements, bankruptcy orders or repossessions. Some of the information that you provide us about this claim may be passed to other insurance companies you tell us about. They will give us information about your policy with them, and we may ask them to pay a contribution to this claim. A contribution payment is normal practice where two or more policies cover the same thing.

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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