Fillable Form 1: General Claim Form You the Policyholder (NIG)

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Form 1: General Claim Form You the Policyholder (NIG)

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The Form 1: General Claim Form You the Policyholder (NIG) form is 4 pages long and contains:

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Country of origin: UK
File type: PDF

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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
You the Policyholder
1
General Claim Form
NIG Commercial Claims P O Box 1151 Bromley BR1 9WB
a Date (dd/mm/yyyy) Time
am pm
b Where did the loss/damage occur?
c Describe fully how loss/damage occurred.
d Were the police notified? Yes No
If yes, address of station
e
Date of notification to police Police Crime Reference No
f Were the fire brigade called? Yes No
If yes, address of station
g
Was any person(s) responsible for loss/damage?
Yes No
If yes, say why
h
Name and address of person(s) responsible
i If they are Insured against causing this incident state Insurers name,
address and policy number
Circumstances of the Claim
2
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.
a Type of premises
b Were the premises unoccupied? Yes No
If yes, when last occupied?
c
Are you the owner of the premises? Yes No
If no, give name/address of owner
d
Are you responsible for repairs? Yes No
e 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
f
What is the total of buildings and/or trade contents/other contents/
stock/plant and machinery of or on the premises?
i b
uildings
i
i
a
ll contents
iii stock iv plant and machinery
g Have you ever suffered similar loss/damage?
Yes No
If yes, give details and whether claim made on Insurers
G
eneral Information (where applicable)
3
a Cause of breakdown of freezer
b When was the freezer purchased/hired?
c Is the freezer currently subject of a Maintenance/Service Agreement?
Yes No
If yes, name/address of engineers with whom agreement arranged
Complete for Deterioration of Frozen Food only
4
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
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.
NIG1101T/06/15
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Form 1: General Claim Form You the Policyholder (NIG)

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Completed 27 March 2021

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