Carmichael & Company | Loss Adjusters | Claims

For existing claimants Please complete the below form. Alternatively you can download this form in either Adobe PDF or Microsft Word DOC format. Please follow the links below. To download Adobe Acrobat Reader please use the Adobe Acrobat link.

	Download New Claim Form (Adobe PDF)		Download Adobe Acrobat Reader
	Download New Claim Form (Microsoft Word)

To facilitate consideration of your claim, it is important that sections 1 & 2 and the details of the claim in section 3 are completed. Available estimates should be forwarded to Carmichaels by post or as scanned Acrobat PDF files.

Damaged property should be retained for inspection if required and protected from deterioration.

Your Details:
	Full Name (Company Name if Applicable)


	Address (Company Address if Applicable)


	Telephone Number (Company Telephone Number if Applicable)


	Email Address (If Applicable)


	Please Re-Enter your Email Address (If Applicable)

Insurer's Details:
	Name of Insurance Company

	Insurer's Claim Number

	Broker Reference Number: (If Applicable)

Section 1:
	Name of Insured

	Insured Address

	Telephone Number (Business)

	Telephone Number (Home)

	Telephone Number (Mobile)

	Email Address

	Business Occupation

	Policy No

	Branch

	Renewal Date

	a) Is the insured registered as a taxable person for VAT?
	Yes No
	b) If the answer to a is YES, do you obtain full remission of input tax from customs?
	Yes No
	c) If the answer to (b) is no (ie. you are "partially exempt"), what percentage are you provisionally assessed as being able to recover?

The Event:
	Date and Time

	Place

	When & whom discovered

	State fully how it happened

	If known, state name and address of person causing loss or damage (If your claim is for an article lost, stolen or maliciously destroyed or damaged, the Police must be advised promptly)

	State the date you advised the Polce and the name of the station

Section 2: Premises/Property Damaged or Lost
	Are you the sole owner?
	Yes No
	If NO, state name and address of owner
	N/A
	Give names of any other party(ies) with interest in property.
	N/A
	Are you responsible by agreement for the premises/property?
	Yes No
	State purpose(s) for which the premises are used

	If a house, was it fully furnished for habitation?
	Yes No
	To what extent are the premises left uninhabited?
	a) By Day

	b) By Night

	c) If by day and night, since what date?

State total value of insured premises/property (not for glass or wash basin claims)
	i) Household Claims
	Building:	£
	Contents:	£

	ii) Other Claims
	Building:	£
	Machinery:	£
	Fixtures & Fittings:	£
	Stock:	£
	All Other Contents:	£

	Are there any other insurance's on the property? Yes No
	If Yes give details:

	Have you ever before made a claim of this nature on any insurance company or underwriter?
	Yes No
	If Yes give details:

	Nature of Claim:

	Name of Insurers:

	Amount Paid:
	£

Section 3: Details of Claim
	Please provide as much detail as possible regarding your claim. Guidelines for information required:
	For breakages describe the item in terms of its size, type, age and situation. Give an estimate for its replacement cost. For damage to premises describe the specific damage to each room, include the age of the building/damaged items, the date when last decorated, and include the amount of a tradesman's estimate for repairs. For articles specifically insured describe the article, include an estimate for the amount to replace or repair it, and state when and where it was originally acquired, and its purchase price.

In submitting this electronic claim form, I / we declare that the statements made are true and correct to the best of my/our knowledge and belief and I/we claim the amount shown in respect of the items detailed above.