Please answer all questions. This will help us process your claim quickly. If you need more space to answer any of the questions, please use a separate sheet of paper. Any attachments will form part of this claim report and the declaration will include them.

Equipment/Appliance Damage Details

Please supply as much details as possible to assist in processing the claim.

Who reported the incident to you?

When was it reported?

Please identify any witnesses

Claims This policy does not provide cover in relation to events that occurred before the contract was entered into Excess An excess is applicable when we pay you for your claim, see the policy for details. Cover The Company will, at its option: Reinstate or repair the property or any part thereof; or Pay the cost of such reinstatement or repair subject to due allowance for wear, tear, depreciation or betterment, but the Company will not be liable to make any payment until the cost of reinstatement or repair is actually incurred; or Pay the insured the value of the property at the time of the destruction, loss or damage. Non-disclosure If you fail to comply with your duty of disclosure the insurer may be entitled to reduce its liability under the contract in respect of the claim, or may cancel the contract. If your non-disclosure is fraudulent, the insurer may also have the option of avoiding the contract from its beginning.

I declare that the property claimed for has been lost, destroyed or damaged in the manner described and belief the information in this form is true and correct and I have not withheld any relevant information. I consent to the Insurance Underwriter using my personal information I have provided on this form for the purpose of processing this claim. I understand that if I choose not to provide the required details, this is my choice, however, the Insurance Underwriter may not be able to process the claim. I consent to the Insurance Underwriter disclosing my personal information to other insurers, an insurance reference service or as required by law. I consent to the Insurance Underwriter also disclosing my personal information to and/or collecting additional information about me from investigators or legal advisors.