Commercial Vehicles
 
Property Claim Form
Who is your broker?
Please complete Policy Holder, Event and Property Sections.
Only complete the relevant section(s) of Details of Claim
Policy Holder (required)
Name of insured
Policy Number
Your Email
Address
Postcode
Occupation
Tel. No Home
Tel. No Office
Are you registered under VAT regulations?
Event
Date and Time
Place
When and by whom discovered?
State in full detail the cause of the loss or damage?
In case of theft, loss or malicious act, Police must be informed promptly. State date Police advised and name of station and crime ref, if known.
Property
Are you the sole owner of the Property for which the claim was made?
If No give details of interested parties
If applicable, please confirm how entry was gained to your premises
Were the premises occupied at the time of occurrence?
If No, on what date and hour were they last occupied?
State total value of Insured Property
Buildings £
Contents £
Have you previously made a property claim against any Insurer?
If Yes, give particulars
Where there at the time of occurrence any other insurances in force on the said property, whether effected by you or by any other person?
If Yes, give particulars
Details of Claim | Breakage of glass/mirrors
Where situated
Size
If mirror when purchased and for what price
Amount Claimed
Important - Please attach estimate for Repair/Replacement
Details of Claim | Wash basin and/or sanitary fixtures
Description and colour of broken fixture
When purchased and for what price
Amount Claimed
Details of Claim | Underground pipe/cable
Does the damaged pipe/cable extend from the house to the public mains?
If no, has the local authority accepted any responsibility?
What was cause of damage?
Length of section of pipe/cable (to be) renewed
Age of pipe/cable
Important - Please attach estimate for Repair/Replacement
Details of Claim | Buildings
Specify separately each room or building damaged or destroyed Age of building or damaged fixture/fittings Date when last decorated Amount of estimate (please attach Repair or Replacement Estimate) Deduction for previous depreciation, alteration or improvements Net amount claimed
Details of Claim | Buildings
Description of articles lost, damaged or destroyed Date acquired From whom obtained. Name and address Original cost (receipts wherever possible) Replacement cost or cost or repairs (where applicable) Deduction for wear and tear (where applicable) Value of salvage
Use separate sheets if necessary

I/We declare the above is a full and accurate statement, and I/We therefore claim the sum of £ as the amount due to me/us in respect of the loss of or damage to the property detailed. The damage property should be protected from further deterioration, but should not be disposed of until permission is given by the Company or the Appointed Adjusters.

Notice
Insurers pass information to the Claims and Underwriting Exchange Register, run by Insurance Database Service Ltd (ISD Ltd) and the Motor Insurance Anti-Fraud and Theft Register, run by the Association of British Insurers (ABI). The aim is to help us to check information provided and also to prevent fraudulent claims. Under the conditions of your policy, use must tell us about any incident (such as an accident or theft) which may or may not give rise to a claim. We will pass information relating to this incident to the registers.

Data Protection Notification
We may use personal and business details you give us, or which are supplied by third parties, to consider your claim, to search the files of credit reference agencies who may keep a record of the search, to carry out such financial and other enquiries as we consider necessary to evaluate the claim and assist in making a decision regarding the claim, and the compliance business reviews. We may also share these with other insurance organisations and selected other parties to handle claims and prevent fraud. 		Personal details may be transferred to countries outside the EU. They will at all times be held securely and handled with the utmost care in accordance with all principles of UK Law. We will store such personal derails on computer but will not keep them for longer than necessary. Under terms of the Data Protection Act 1998, individuals are entitled to a copy of all the information we hold about them.

VERY IMPORTANT - FRAUDULENT AND EXAGGERATED CLAIMS Deliberately exaggerated claims could invalidate your policy cover. Insurance fraud is a crime and liable to prosecution.
 The above answers to our questions will be the basis of consideration of your claim. You must ensure that all information is true and correct to the best of your knowledge and belief, and that all material facts have been disclosed. A material fact is one that is likely to influence us in the assessment or acceptance of this claim, or one that is likely to influence our consideration of cover under the terms of your policy. If you are in any doubt as to whether a fact is material, you must disclose it.

FAILURE TO DO THIS MAY MEAN THAT YOUR POLICY BECOMES INVALID AND A CLAIM PAYMENT WLL NOT BE MADE.
I/We declare the foregoing particulars to be correct according to our information and belief. I/we understand that you may seek information from other insurers to check the answers I/We have provided. This report is made in the bona fide belief that litigation may ensue and to enable solicitors and/or agents to conduct such litigation and advice in relation thereto.
Accept the Terms
©Platinum Assist Limited 2009
Platinum Assist Limited is authorised and regulated by the Financial Services Authority.
Platinum Assist Limited Registered Address: Second Floor Cardiff House Tilling Rd London NW2 1LJ Company No. 6451749 Registered in England and Wales.