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
a Date of accident/loss (dd/mm/yyyyy) Time
am pm
b Exact place where accident/loss occurred
c Were you the owner of the goods? Yes No
If no, please give name and address of owner
Complete Section 3, 4 or 5 as applicable for Goods in Transit by post,
road or National Rail/National Carriers
Circumstances of the Claim
2
a Registration No. of vehicle
Make Year
b Type of Vehicle: Platform Articulated
Fully Enclosed Dropside Tanker
Carrying Capacity
c Are you the owner of the vehicle? Yes No
If no, please give name and address of owner
d
Name and address of Motor Insurers of the vehicle
e Names of men employed on the vehicle with age and years of service
Name Age Service
f Address of police station to which accident/loss was reported
years
years
Road Haulage
3
Goods in Transit 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.
R
oad Haulage
continued
3
g Date reported (dd/mm/yyyyy) Time
am pm
h Please state exactly how the loss/damage occurred and what action
was taken immediately afterwards
i If the loss/damage was caused by the fault of any person(s), please
g
ive the names and addresses
j Name and address of consignors
k Address where the goods were picked up
l Did driver count/check consignment?
m How were the goods packed?
n How were the goods stowed, sheeted etc?
o Name of occupiers and address to which goods were conveyed
p If goods were damaged where can the property be inspected?
q What receipt was given i.e. Clear or Qualified in some way when:
i Goods were picked up/loaded
i
i
G
oods were delivered/unloaded
r If you were principal contractor give name and address of sub-
contractor
s If you were sub-contractor give name and address of your principals
t What conditions of carriage apply?
u Load/consignment description:
i Nature of goods
ii Number of packages
iii Total weight
iv Total value of whole load £ (include damaged/loss portion)
v Damage description:
i Nature of goods
ii Number of packages
iii Total weight
Value of goods lost/damage
Value of salvage (if any)
Please attach invoice/account, copy receipt given for the goods,
delivery note (when goods were delivered) and all other relevant
documents and correspondence.
£
£
a Nature of goods
Total number parcels/cartons despatched
b P
osted at
By Parcel Letter Registered
Reordered Delivery Post
c Registered/Recorded post receipt no.
Loss of
Damage to
Shortage from
d If claim for damage/pilferage has packing been kept for inspection?
e T
otal number of items missing from parcel
f Cost Price
Value of Salvage
Cost of Repairs
g Date Post Office advised
(dd/mm/yyyy)
Please attach all correspondence with Post Office, customer and copy
of invoice and compilation of claim when necessary.
£
£
£
Parcels
Parcels
Parcels
P
ost
4
Post Office
a Nature of goods
Total number parcels/cartons despatched
b National Rail National Carriers Ltd
Depot/Station Region
c Goods despatched at Boards Owner Risk
(Attach copy of Consignment Note)
d
Weight of whole consignment Value of whole consignment
e Weight of loss/damaged/ Value of affected part
pilfered part
f Loss of
Damage to
Shortage from
g Cost Price
Value of Salvage
Cost of Repairs
h Date Carriers/Railway advised
(dd/mm/yyyy)
Please attach all correspondence with National Rail/National Carriers
Ltd., customer and copy of invoice and completion of claim when
necessary
£
£
£
Parcels
Parcels
Parcels
National Rail/National Carriers Ltd
5
£
£
I/We declare the foregoing particulars to be true and complete and that I/we hold no other policy indemnifying me/us in respect of this claim.
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. I/We understand that you may seek information from other
insurers to check the answers I/we have provided.
Signature Date (dd/mm/yyyy)
Declaration
6
NIG1113Q/06/15
NIG policies are underwritten by U K Insurance Limited, Registered office: The Wharf, Neville Street, Leeds LS1 4AZ.
Registered in England ans 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.