Carmichael & Company | Loss Adjusters | Claims | New Instruction

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New Instruction

Satisfaction Form

The below form is for submission of new instructions by insurers. Please complete all sections and click on the submit button to send your details. 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 Instruction Form (Adobe PDF)		Download Adobe Acrobat Reader
	Download New Instruction Form (Microsoft Word)

Help is given every step of the way whilst using this form, just place your mouse over the 'information' sign.

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:
	Date

	Claims Reference Number

	Insurer Name

	Branch Address

	Telephone Number

	Fax Number

	Email Address

The Insured:
	Surname

	Title / Initial

	Insured Address

	If the loss is at a different address, please state the full address incl. Post Code

	Telephone Number (Business)

	Telephone Number (Home)

	Telephone Number (Mobile)

	Fax Number

	Email Address

Broker Details:
	Broker Reference Number

	Broker Name

	Broker Address

	Telephone Number

	Fax Number

	Email Address

Policy Details:
	Policy Number

	Policy Type

Household Cover: (see below for commercial cover)
	Buildings
	£
	Contents
	£
	Alternative Accomodation
	£
	All Risks

Commercial Cover:
	Buildings
	£
	Machinery & Plant
	£
	Stock
	£
	Loss of Profits
	£
	Other

Warranties/Endorsements:

Loss Details:
	Loss Type

	Loss Date

	Loss Estimate
	£

Special Instructions:

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Please enter the Date today.

Please enter your claims reference number.

Please enter the name of your Insurance Company.

Please enter the branch address of your Insurance Company.

Please enter the telephone number of your Insurance Company.

Please enter the fax number of your Insurance Company.

Please enter the email address of your Insurance Company.

Please enter the Surname of the Insured person.

Please enter the title and or initial of the Insured person.

Please enter the FULL address of the Insured person.

If the loss occured at a different address from the Insured address then please state the FULL address here.

Please enter the business telephone number of the Insured person.

Please enter the home telephone number of the Insured person.

Please enter the fax number of the Insured person.

Please enter the email address of the Insured person if available.

Please enter your Broker reference number if available.

Please enter the name of your Broker company if available.

Please enter the FULL address of your Broker company if available.

Please enter the telephone number of your Broker company if available.

Please enter the fax number of your Broker company if available.

Please enter the email address of your Broker company if available.

Please enter your policy number.

Please enter your policy type.

Please enter the insured covered amount for buildings.

Please enter the insured covered amount for contents.

Please state any other alternative accomodation.

Please enter All Risks information.

Please enter your commercial cover for buildings.

Please enter your commercial cover for contents.

Please enter your commercial cover for stock.

Please enter your commercial cover for loss of profits.

Please enter any other commercial cover.

Please enter any Warranties/Endorsements.

Please select the type of loss that occured.

Please enter the loss date.

Please enter the loss estimate.

Please enter any special instructions you may have.

Please enter the Insured's mobile phone number if applicable.

Please enter your name in FULL

Please enter your address in FULL

Please enter your contact telephone number in FULL

Please enter your email address (If Applicable)

Please re-enter your email address
(If Applicable)