Miscellaneous Claim Form Name of Insured (required) Physical Address (required) Postal Address (required) Mobile Number Address where loss occured Time of loss Loss Date (required) Describe fully how the loss occured Details Was the premises occupied? ---NoYes If not when was it last occupied Estimate the value of the damaged property Is the the destroyed property insured on another policy? ---NoYes If Yes State Insurer Any additional Comments Attach 3 Quotations from reputable garage below By submitting this form you accept the Terms & Conditions
