Please answer all the questions fully
Full Name
Policy Number:	Policy Start Date:	Policy End Date:
Address of property where loss or damage occured When did this damage occure What was the cause of the loss or damage, and how did it occcur? By whom was the loss or damage discovered In the case of theft, or malicious damage, when were the police notified and which station? For what purpose (e.g. Home, Office, Shop etc.) were the premises used for at the date of the loss or damage? If unoccupied, please state why. If any alteration in the property has occurred since the policy was issued or endorsed please give details. Does the property in respect of which this claim is made: (a) Belong solely to you. If not please name other interested party (e.g. Mortgagee etc.) (b) Have coverage under any other policy of insurance? If so please provided details. Have you previously suffered any loss or damage from a similar cause in this or other premises? If so please provide details. Please state the probable amount of the entire loss.
A full breakdown of the amounts being claimed must be provided: Buildings: A Builder's estimate must be provided (at your expense) which details the full repair or rebuilding cost. The cost of any improvements should not be included in this etsimate. Contents: It is essential to provide a full list of all articles lost, destroyed or damaged with the details required below. Description of Articles and Quantity
Date Purchased	Original cost	Replacement cost	Value after damage	Amount claimed
Description of Articles and Quantity
Date Purchased	Original cost	Replacement cost	Value after damage	Amount claimed
Description of Articles and Quantity
Date Purchased	Original cost	Replacement cost	Value after damage	Amount claimed
Description of Articles and Quantity
Date Purchased	Original cost	Replacement cost	Value after damage	Amount claimed
Description of Articles and Quantity
Date Purchased	Original cost	Replacement cost	Value after damage	Amount claimed
Description of Articles and Quantity
Date Purchased	Original cost	Replacement cost	Value after damage	Amount claimed
Additional information and/or comments: