Insurance claim enquiry form

Name *

Address

Telephone *

E-Mail

Subject *

What type of loss have you suffered?Please Select an OptionFireTheftWater DamageOther; please give details below.

What value do you estimate your claim to be?Please select an option£3000 - £10000£10000 - £50000In excess of £50000

Have your insurers admitted liability?YesNoClaim refused; please give details below.

Have you submitted a claim to your insurers or their Adjusters?Yes - in writingYes - verballyNo

Comments / Details of claim:

2 + 6 = ?Please prove that you are human by solving the equation *