Breakdown Insurance Claim Form

"*" indicates required fields

Name

This field is for validation purposes and should be left unchanged.

Insured Name*

Email*

Phone Number*

Insurance Product*

Address*

Policy number*

Date of loss*

Location of loss*

Describe as fully as possible how the loss occurred*

Is the machinery / appliance under manufacturer's warranty? If YES, has a claim been made under the warranty?*

Machinery

Make of motor*

Machinery serial number*

Voltage*

Electronic item

Electronic item serial number*

Electronic item age*

Insurance history

Description of goods*

Quantity (optional)

Total Sum claimed*

Details and cause of damage/breakdown

Have you had any claims in the last 5 years? (YES / NO If Yes, provide details.)*

Has any Insurance Company refused to renew or cancelled/terminated a policy? Has any Insurance Company refused a claim? (YES / NO If Yes, provide details.)*

Have you been convicted of or had any fines or penalties imposed for any criminal offences in the last 10 years? (YES / NO If Yes, provide details.)*

Additional Information (optional)

Upload photo or document

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, xls, xlsx, Max. file size: 5 MB, Max. files: 15.