CBC UK LIMITED

COMMERCIAL PROPERTY DAMAGE CLAIM FORM

POLICY DETAILS
Assured: Risk Address: Telephone No.: Email Address:
Y N

Policy Number: Inception Date of Policy:

Postcode:

Are you VAT Registered (Y/N)? If Yes, please provide Reg. Number and status:

LOSS DETAILS
Date and Time of Loss: Location where loss occurred: Name of witness: Address of witness:

Postcode: Postcode:
Y N

Is the property unfurnished? By whom was loss discovered: If fire, please state precise cause of outbreak: If theft, please advise how entry was gained to the premises:
Y N

When was the property last occupied prior to the loss? Is there any other insurance covering the property concerned? If 'YES' please provide: Insurance Co.: Address:
Y N

Was entry/exit by forcible and violent means? Have the police been notified? If 'YES' please provide: Police Station: Crime Reference Number:

Postcode: Policy Number: Tel. Number: Contact:

PROPERTY OWNERSHIP
Who is the owner of the property?

If you are not the owner but are responsible for repairs, please give details of the Agreement imposing the responsibility:

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CIRCUMSTANCES OF THE LOSS/DAMAGE

Please provide the fullest possible details of the circumstances giving rise to the loss or damage: Any other information you feel may be of assistance to us in handling this claim:

DETAILS OF THE ITEMS LOST/DAMAGED/STOLEN

Full Description of Item Age of Item (years/months) Purchase Price Amount Claimed

1 2 3 4 5
(Continue on a separate sheet if necessary)

TOTALS:

If the claim is for damage to the buildings or fixtures and fittings, please provide the following: Details of the damage:

Estimated cost of repair: Please submit 2 estimates for repairs to damaged property. If the property cannot be repaired, please submit two estimates for replacement. Details of any other losses in the last 6 years: (excluding motor/marine/aviation losses)

DECLARATION
I hereby declare that the details given on this form are true and complete to the best of my knowledge. Name: Signature of Client: Date:

Please send signed completed form to: CBC UK Limited, Mansell Court, 69 Mansell Street, London E1 8AN Tel: 020 7265 5600 / Fax: 020 7702 4784 / Email: claire.feakins@cbcmail.co.uk
CBC Claim Reference Number:
CBC UK LIMITED 2004

3/2/2012

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CBC UK LIMITED
COMMERCIAL PROPERTY DAMAGE CLAIM FORM
POLICY DETAILS
Assured: Risk Address: Telephone No.: Email Address:
Y N

Policy Number: Inception Date of Policy:

Postcode:

Are you VAT Registered (Y/N)? If Yes, please provide Reg. Number and status:

LOSS DETAILS
Date and Time of Loss: Location where loss occurred: Name of witness: Address of witness:

Postcode: Postcode:
Y N

Is the property unfurnished? By whom was loss discovered: If fire, please state precise cause of outbreak: If theft, please advise how entry was gained to the premises:
Y N

When was the property last occupied prior to the loss? Is there any other insurance covering the property concerned? If 'YES' please provide: Insurance Co.: Address:
Y N

Was entry/exit by forcible and violent means? Have the police been notified? If 'YES' please provide: Police Station: Crime Reference Number:

Postcode: Policy Number: Tel. Number: Contact:

PROPERTY OWNERSHIP
Who is the owner of the property?

If you are not the owner but are responsible for repairs, please give details of the Agreement imposing the responsibility:

3/2/2012

Page 3 of 4

S:\Fine Art\Martyn\Misc Forms\86601265.xls.ms_office

CIRCUMSTANCES OF THE LOSS/DAMAGE

Please provide the fullest possible details of the circumstances giving rise to the loss or damage: Any other information you feel may be of assistance to us in handling this claim:

DETAILS OF THE ITEMS LOST/DAMAGED/STOLEN

Full Description of Item Age of Item (years/months) Purchase Price Amount Claimed

1 2 3 4 5
(Continue on a separate sheet if necessary)

TOTALS:

0.00

0.00

If the claim is for damage to the buildings or fixtures and fittings, please provide the following: Details of the damage:

Estimated cost of repair: Please submit 2 estimates for repairs to damaged property. If the property cannot be repaired, please submit two estimates for replacement. Details of any other losses in the last 6 years: (excluding motor/marine/aviation losses)

DECLARATION
I hereby declare that the details given on this form are true and complete to the best of my knowledge. Name: Signature of Client: Date:

Please send signed completed form to: CBC UK Limited, Mansell Court, 69 Mansell Street, London E1 8AN Tel: 020 7265 5600 / Fax: 020 7702 4784 / Email: insure@cbcmail.co.uk
CBC Claim Reference Number:
CBC UK LIMITED 2004

3/2/2012

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