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Home Insurance Claim
Policy Owner Details
Type of Claim
*
Please Select
Fire
Theft/Burglary
Policyholder Type
*
Please Select
Private
Corporate
Policy Number
*
Phone No
*
Email Address
*
Address
*
City
*
State
*
Details of Incident
Date of Incident (yyyy-mm-dd)
*
Time of Incident
*
Where Did the Incident Occur?
*
Brief Details of Incident
*
Damaged Property/ Stolen Content Details
Brief Description of Property/Content Damaged or Stolen
*
Value of Property/Content Damaged or Stolen
*
Pictures of Incident/Damaged Content
All Attachments Must be In PDF or JPEG Format
Upload Picture 1
*
Upload Picture 2
*
Upload Picture 3
*
Upload Supporting Documents(if any)
Estimate of Repairs(If Building)
Statement of claim (Sheet showing quantities and value of Property/Stock damaged/Stolen)
*
Purchase Receipt/Invoice of stolen items(If Theft/Burglary)
Estimate Of Claim
*
Witness 1 Name and Telephone Number (Name/Tel etc)
*
Witness 2 Name and Telephone Number (Name/Tel etc)
Statement of Authenticity/Truth of Details Given Above (Please Tick Box).
*
Submit
