Fillable Form 1: All Risks/Loss Claim Form (NIG)

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Form 1: All Risks/Loss Claim Form (NIG)

On average this form takes 45 minutes to complete

The Form 1: All Risks/Loss Claim Form (NIG) form is 4 pages long and contains:

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  • 0 check-boxes
  • 181 other fields

Country of origin: UK
File type: PDF

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You the Policyholder
1
a Date (dd/mm/yyyy) Time
am pm
b Where did the loss/damage occurred
c Describe fully how the loss/damage occurred
d Where and when was the property last seen?
e Who was last to see the property?
f Were the police notified? Yes No
If yes, address of station
g
Date of notification to police Police Crime Reference No
h What steps have been taken to recover the property?
i In whose custody was the property at the time of loss/damage?
j Has a formal claim been made against the person(s) in charge of
property at time of loss/damage?
Yes No
Date of claim (dd/mm/yyyy)
k Was any other person(s) responsible for loss/damage?
Yes No
If yes, say why
Circumstances of the Claim
2
Name of the Insured
Address
Town County
Postcode Date Premium Paid
Occupation Telephone Number
Policy Number Value Added Tax. Are you
a registered person or company? Yes No
Please state the number of bedrooms (include all rooms designated as bedrooms even if not used as such)
All Risks/Loss Claim Form
NIG Commercial Claims P O Box 1151 Bromley BR1 9WB
Please note - you can complete this form on screen. When completing please use the tab and arrow keys to move between the relevant
fields. Ensure you do not use the return or enter keys.
If completing by hand, please answer all questions using BLOCK CAPITALS.
l Name and address of person(s) responsible m If they are Insured against causing this incident state their Insurers
name, address and policy number
C
ircumstances of the Claim
continued
2
a Is there any other policy in force providing cover for this incident?
Yes No
If yes, give details to include Insurers name/address and policy
number
b
Have you ever suffered similar loss/damage?
Yes No
If yes, give details and whether a claim was made on Insurers
General Information (where applicable)
3
List/Description of Article(s) or
Property destroyed/damaged
Extent of damage
Owner of Article(s) or Property
W
here acquired (Name/address of
r
etailer etc. or in the case of gift, the
g
iver)
D
ate of acquisition (dd/mm/yyyy)
C
ost Price
R
eplacement Cost
Value at the time of damage allowing
for wear and tear where applicable
S
alvage value
(
value, if any, after claim)
Sum Claimed
List/Description of Article(s) or
Property destroyed/damaged
Extent of damage
Owner of Article(s) or Property
W
here acquired (Name/address of
r
etailer etc. or in the case of gift, the
g
iver)
D
ate of acquisition (dd/mm/yyyy)
C
ost Price
R
eplacement Cost
Value at the time of damage allowing
for wear and tear where applicable
S
alvage value
(
value, if any, after claim)
Sum Claimed
List/Description of Article(s) or
Property destroyed/damaged
Extent of damage
Owner of Article(s) or Property
W
here acquired (Name/address of
r
etailer etc. or in the case of gift, the
g
iver)
D
ate of acquisition (dd/mm/yyyy)
C
ost Price
Replacement Cost
Value at the time of damage allowing
for wear and tear where applicable
Salvage value
(value, if any, after claim)
Sum Claimed
List/Description of Article(s) or
Property destroyed/damaged
Extent of damage
Owner of Article(s) or Property
W
here acquired (Name/address of
r
etailer etc. or in the case of gift, the
g
iver)
D
ate of acquisition (dd/mm/yyyy)
C
ost Price
Replacement Cost
Value at the time of damage allowing
for wear and tear where applicable
Salvage value
(value, if any, after claim)
Sum Claimed
List/Description of Article(s) or
Property destroyed/damaged
Extent of damage
Owner of Article(s) or Property
Where acquired (Name/address of
retailer etc. or in the case of gift, the
giver)
Date of acquisition (dd/mm/yyyy)
Cost Price
Replacement Cost
Value at the time of damage allowing
for wear and tear where applicable
Salvage value
(value, if any, after claim)
Sum Claimed
List/Description of Article(s) or
Property destroyed/damaged
Extent of damage
Owner of Article(s) or Property
Where acquired (Name/address of
retailer etc. or in the case of gift, the
giver)
Date of acquisition (dd/mm/yyyy)
Cost Price
Replacement Cost
Value at the time of damage allowing
for wear and tear where applicable
Salvage value
(value, if any, after claim)
Sum Claimed
List/Description of Article(s) or
Property destroyed/damaged
Extent of damage
Owner of Article(s) or Property
Where acquired (Name/address of
retailer etc. or in the case of gift, the
giver)
Date of acquisition (dd/mm/yyyy)
Cost Price
Replacement Cost
Value at the time of damage allowing
for wear and tear where applicable
Salvage value
(value, if any, after claim)
Sum Claimed
List/Description of Article(s) or
Property destroyed/damaged
Extent of damage
Owner of Article(s) or Property
Where acquired (Name/address of
retailer etc. or in the case of gift, the
giver)
Date of acquisition (dd/mm/yyyy)
Cost Price
Replacement Cost
Value at the time of damage allowing
for wear and tear where applicable
Salvage value
(value, if any, after claim)
Sum Claimed
I/We declare that no material information has been withheld and that all statements on this form are true to the best of my/our knowledge and belief.
In addition the articles and property belong to the persons named and no other person has any interest whether as Owner, Mortgagee or Trustee. I/we
understand that you may seek information from other insurers to check the answers I/we have provided, and I/we authorise the giving of such
information for such purposes.
Insurers and their agents share information with each other to prevent fraudulent claims and to decide whether to accept your proposal and,
if so, on what terms via the Claims and Underwriting Exchange Register, operated by Insurance Database Services Ltd. A list of participants
is available on request. The information you supply on this form, together with the information you have supplied on your application form
and other information relating to the claim, will be provided to participants.
Signature Date (dd/mm/yyyy)
Please complete and return this form as soon as possible. Damaged property should be protected from further deterioration but not disposed of
without prior reference to the Company. If the claim is for repairable damage i.e. buildings, a Trademan’s estimate will be required.
List/Description of Article(s) or
Property destroyed/damaged
Extent of damage
Owner of Article(s) or Property
W
here acquired (Name/address of
r
etailer etc. or in the case of gift, the
g
iver)
D
ate of acquisition (dd/mm/yyyy)
C
ost Price
R
eplacement Cost
Value at the time of damage allowing
for wear and tear where applicable
S
alvage value
(
value, if any, after claim)
Sum Claimed
List/Description of Article(s) or
Property destroyed/damaged
Extent of damage
Owner of Article(s) or Property
W
here acquired (Name/address of
r
etailer etc. or in the case of gift, the
g
iver)
D
ate of acquisition (dd/mm/yyyy)
C
ost Price
R
eplacement Cost
Value at the time of damage allowing
for wear and tear where applicable
S
alvage value
(
value, if any, after claim)
Sum Claimed
List/Description of Article(s) or
Property destroyed/damaged
Extent of damage
Owner of Article(s) or Property
W
here acquired (Name/address of
r
etailer etc. or in the case of gift, the
g
iver)
D
ate of acquisition (dd/mm/yyyy)
C
ost Price
Replacement Cost
Value at the time of damage allowing
for wear and tear where applicable
Salvage value
(value, if any, after claim)
Sum Claimed
List/Description of Article(s) or
Property destroyed/damaged
Extent of damage
Owner of Article(s) or Property
W
here acquired (Name/address of
r
etailer etc. or in the case of gift, the
g
iver)
D
ate of acquisition (dd/mm/yyyy)
C
ost Price
Replacement Cost
Value at the time of damage allowing
for wear and tear where applicable
Salvage value
(value, if any, after claim)
Sum Claimed
List/Description of Article(s) or
Property destroyed/damaged
Extent of damage
Owner of Article(s) or Property
Where acquired (Name/address of
retailer etc. or in the case of gift, the
giver)
Date of acquisition (dd/mm/yyyy)
Cost Price
Replacement Cost
Value at the time of damage allowing
for wear and tear where applicable
Salvage value
(value, if any, after claim)
Sum Claimed
List/Description of Article(s) or
Property destroyed/damaged
Extent of damage
Owner of Article(s) or Property
Where acquired (Name/address of
retailer etc. or in the case of gift, the
giver)
Date of acquisition (dd/mm/yyyy)
Cost Price
Replacement Cost
Value at the time of damage allowing
for wear and tear where applicable
Salvage value
(value, if any, after claim)
Sum Claimed
NIG1107U/06/15
NIG policies are underwritten by U K Insurance Limited, Registered office: The Wharf, Neville Street, Leeds LS1 4AZ.
Registered in England and Wales No 1179980. U K Insurance Limited is authorised by the Prudential Regulation Authority
and regulated by the Financial Conduct Authority and the Prudential Regulation Authority.
Calls may be recorded.
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Form 1: All RisksLoss Claim Form (NIG)

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Completed 27 March 2021

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