General Insurance Claim FormSubmit your claim"*" indicates required fieldsCompanyThis field is for validation purposes and should be left unchanged.Insured Name*Address*Email* Phone*Policy number*Insurance Product*Circumstances of property loss or damageDate of loss* DD slash MM slash YYYY Time of loss*Please state full details of how loss or damage occurred*Police report number? (optional)Description of property loss or damagePlease list description, sum claimed and purchase date of each item*Total sum claimed*Insurance historyHave 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)Upload photo or document Drop files here or Select filesAccepted file types: jpg, jpeg, png, pdf, doc, docx, xls, xlsx, Max. file size: 5 MB, Max. files: 15.This field is hidden when viewing the formForm Title GET A QUOTEDiscover the Elliott Insurance difference request a quote