General Claim Form Insurely

PART A: POLICY HOLDER
Full name of insured: Company
Postal Address
Phone

Area CodePhone Number
Email
example@example.com
Bank Account No. For Direct Credit Payment
PART B: CIRCUMSTANCES OF LOSS. PLEASE COMPLETE IN ALL CASES
Date

DayMonthYear
Date
Day
Time
Where did the loss occur?
Please explain what happened
Is there any other insurance with any Company relating to this loss?
If so, give particulars
If loss caused by another person please give name and address
Have you, within the past 5 years, made a claim against any Insurance Company?
If so, please supply details including Company name
Are you the sole owner of the property concerned?
YesNo
If No, supply details of other interest and party concerned
If burglary, loss, or theft claim
To which Police Station was it reported?
Date Reported

DayMonthYear
Date
Acknowledgement from attached,
File Upload

Cancelof
If burglary, state means of entry to premises

PART C: PROPERTY SCHEDULE

	Description of property lost or damaged (state each article/item separately)	Date Purchased Price	Present Cost of Replacement	Depreciation for Age & Condition	Value of Salvage (If any)	Amount Claimed

Or Attach Details

Cancelof

PART D: PUBLIC LIABILITY
Name and address of owner of property damaged
Phone No

Area CodePhone Number
Insurance Company
DECLARATION: NOTE* Failure to provide full and truthful information could result in the Claim being declined.

1. I/We agree to The Company disclosing my/our personal information regarding this claim to:

(a) Other parties including other members of the Insurance Industry and the data base of the Insurance Claims Register (ICR Ltd) P.O Box 474, Wellington, where it will be retained and made available to other insurance companies to inspect (b) Parties who have a financial interest in the subject matter of the policy and parties repairing or replacing the subject matter of the claim. (c) I/We understand that I am/We are entitled to have certain rights of access to and correction of the personal information held by The Company and ICR Ltd.

2. I/We agree to The Company obtaining personal information about me/us that is, in The Company's view, relevant to this claim.

(a) From any other party including other members of the Insurance Industry and from Insurance Claims Register Ltd (ICR Ltd) which holds details of claims made by me/us under policies with other insurers.

3. I hereby declare that the answers give above are in every respect correct and I make the solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and Declaration Act 1957.
Insured Signature

Clear
Date

DayMonthYear
Date
(If company, state capacity)
Should be Empty:

PART A: POLICY HOLDER

PART D: PUBLIC LIABILITY