General Insurance Claim Form

Submit your
claim

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Insured Name*

Address*

Email*

Phone*

Policy number*

Insurance Product*

Circumstances of property loss or damage

Date of loss*

Time of loss*

Please state full details of how loss or damage occurred*

Police report number? (optional)

Description of property loss or damage

Please list description, sum claimed and purchase date of each item*

Total sum claimed*

Insurance history

Have you had any claims in the last 5 years? (YES / NO If Yes, provide details.)*

Has any Insurance Company refused to renew or cancelled/terminated a policy? Has any Insurance Company refused a claim? (YES / NO If Yes, provide details.)*

Have you been convicted of or had any fines or penalties imposed for any criminal offences in the last 10 years? (YES / NO If Yes, provide details.)*

Additional information (optional)

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Form Title

GET A QUOTE

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Insurance difference

request a quote

Request A Quote