Title

Full Names

Surname

Date of Birth

Sex

Postal Address

Town / City

County

Post Code

(If different) Risk Address

Town / City

County

Post Code

Email

Telephone Home

Work

Mobile

What is the current total replacement value of the contents of your home?

£

What is the current rebuilding cost of your home?

£

How many bedrooms are in your home?

Is any trade, profession or business carried out in your home?

Have you or any member of your family or any person living with you:

made a claim under any insurance policy in the last five years?

ever been convicted of any offence involving dishonesty, fraud, violence, criminal damage, arson, drugs?

If YES to either of the above, please provide details

Date of Incident

Time of Incident

Where did the incident occur?

State exactly how the incident occurred:

Was your home unoccupied at the time of the incident?

If YES, how long was your home unoccupied prior to the incident?

Was your home unfurnished at the time of the incident?

Was your home or any part of your home lent, let or sub-let at the time of the incident?

Date reported to Police

Address of Police Station it was reported to

Crime reference number given by Police

If theft from a building, how was entry gained?:

Was there any visible signs of forced entry to the building?

Is a burglar alarm fitted to your buildings?

If YES, was it in operation at the time of the incident?

It is necessary for you to prove the loss.

Please enclose documentations such as photographs and receipts to support the existence of the items.

Item 1

Full Description of property (including make, model and serial number)

Date of purchase

Place of purchase

Original Purchase Price

£

Is the item repairable?

Estimated cost of repair / replacement

£

Amount Claimed (£)

£

Item 2

Full Description of property (including make, model and serial number)

Date of purchase

Place of purchase

Original Purchase Price

£

Is the item repairable?

Estimated cost of repair / replacement

£

Amount Claimed (£)

£

Item 3

Full Description of property (including make, model and serial number)

Date of purchase

Place of purchase

Original Purchase Price

£

Is the item repairable?

Estimated cost of repair / replacement

£

Amount Claimed (£)

£

Item 4

Full Description of property (including make, model and serial number)

Date of purchase

Place of purchase

Original Purchase Price

£

Is the item repairable?

Estimated cost of repair / replacement

£

Amount Claimed (£)

£

Item 5

Full Description of property (including make, model and serial number)

Date of purchase

Place of purchase

Original Purchase Price

£

Is the item repairable?

Estimated cost of repair / replacement

£

Amount Claimed (£)

£