Agostini Insurance Brokers - Claims

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Claim Form

* Fields Mandatory

Name of Insured *

Policy Number *

Renewal Date *

Agent *

Address of Insured *

Telephone Number *

Email Address *

Location of Occurrence *

What was the nature of the occurrence?

Date of occurrence *

Hour

Describe briefly what happened, what you believe caused it, and the resultant damage *

For what purposes were the premises being used at the date of occurrence? *

Were the premises occupied at the time of loss? *

If not, when were they last occupied

Has the loss be reported to the relevant authorities?

Police Fire

Date of Notification

Station

Name Officer

Had any element of risk been introduced which was not allowed by the policy?

Are you the sole owner of the property damaged or stolen? *

If not, state full particulars of any other interest

Do you have any other insurance against the loss

If so, give names and addresses of insurers

State total value of contents *

Give details of any previous claims in connection with these or any other premises

	Instructions to be observed in completing this form

	The Claim with respect to BUILDING must be accompanied by two Builder's estimates obtained at the insured's own expense, for the cost of putting the Building into the same state as it was immediately before occurance. No comtemplated improvements are to be included in such estimate.

	The Claim for CONTENTS; it is essential to give a full list of the articles destroyed/damaged with particulars stated below. In the case of Stock, the estimated value immediately before damage must not exceed the value before sale, i.e. it is not to be based on the selling price.

Number of Articles *

Description of Property or Articles destroyed or damaged

Approximate Date of Purchase

Original Cost Price *

Estimated Value before the damage allowing for wear and tear

Estimated Value of Salvage *

Amount Claimed *

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