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Claim Notification Form

Submitting your claim details does not commit you to using our service or to accepting our fee. We will contact you to arrange a suitable appointment to inspect the damage. Such inspection is free of charge and completely without any obligation on your part. Having reviewed the damage and your insurances we will discuss your options with you before you agree to use our services.

Contact Details

Name of Insured:
Contact address:
Telephone No.:
Mobile:
Fax No.:
Email:

Loss Details

Address of loss:
Date of loss:
Time of loss:
Brief description of loss:
Extent of damage:

Insurance Company Details

Has insurance company been notified of the loss?
	YES NO
Broker:
Insurance Company:
Policy Number:

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Claim Notification Form

Contact Details

Name of Insured:

Contact address:

Telephone No.:

Mobile:

Fax No.:

Email:

Loss Details

Address of loss:

Date of loss:

Time of loss:

Brief description of loss:

Extent of damage:

Insurance Company Details

Has insurance company been notified of the loss?

Broker:

Insurance Company:

Policy Number: