AJ Consultancy Ltd Insurance Claim Form V0313

• Client / Site

• Document No.

• Conducted on

  Date

• Prepared by

General property details

• Property Address including flat number

• General construction of property.

• Number of storeys in block

• Storey of property damage

• Type of occupier

  Select Owner Occupier Tenant Occupier

  • Owner Occupier
  • Tenant Occupier

Details of damage.

• Date & Time of incident

  Date

• General description of incident. Witnesses and who discovered the damage.

• Type of damage

  Select Fire Flood Escape of Water/leak Theft Criminal Damage Terrorism Storm/Wind Injury Claim

  • Fire
  • Flood
  • Escape of Water/leak
  • Theft
  • Criminal Damage
  • Terrorism
  • Storm/Wind
  • Injury Claim

• Crime reference number if applicable

• Location of damage

• Photos of damage.

  Media

• General floorplan sketch.

  Drawing

• Estimated cost of damage.

  Select 0-£1000 est damage £1000-£3000 est damage £3000+ est damage

  • 0-£1000 est damage
  • £1000-£3000 est damage
  • £3000+ est damage

• Signature of property owner confirming the information contained in this report to be true and accurate version of events.

  Sign

• Signature of AJC Director approval

  Sign