Your Name
*
First Name
Last Name
Policy Number
This can be found on your policy schedule.
Company Name
Are you VAT registered?
*
Yes
No
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: 00000000000.
Your Address
*
Street Address
Street Address Line 2
City
State / Province
Post Code
Claim Type
*
Loss
Theft
Damage
Incident Date
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Total value of goods in transit
*
Estimated claim value
*
Collection Address
*
Street Address
Street Address Line 2
City
State / Province
Post Code
Delivery Address
*
Street Address
Street Address Line 2
City
State / Province
Post Code
Who packed the Goods?
*
Removal Company
Owner Packed
How were the goods packed
*
Description of what happened
*
Do you accept liability for the claim against you?
*
Photos of Damage
Photos of Damage
Photos of Damage
Evidence of value (Purchase Receipts, Repair Invoice etc )
Copy of the agreement to go ahead with the removal (Invoice, Booking Confirmation etc)
Copy of the Written Claim against you (Text message notifying you of damage)
Valued Inventory
Signature
*
Submit
Should be Empty: