Your Name
*
First Name
Last Name
Policy Number
This can be found on your policy schedule - Will start with a FQ.
Email
*
example@example.com
Phone Number
*
Your Address
*
Street Address
Street Address Line 2
City
State / Province
Post Code
Claim Type
*
Loss
Theft
Damage
Incident Date
*
-
Month
-
Day
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
*
Signature
*
Photos of Damaged Goods
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Evidence of Purchase (Purchase Recipt,Sales Invoice)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Correspodance where you are held liable for the claim
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Freight Invoice (the invoice you charged to move the goods)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Your Motor Insurance Certficate for all the vehicles you own/operate
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: