Specialised Risk Services

• Insurer

• Date

  Date

• Claims Assessor

• Insured

• Claim Number

• Address
  Address

• Customer Name and ID Number

• I, the undersigned, affirm that all information provided in this document is truthful, comprehensive, and entirely accurate. I confirm that, unless explicitly stated otherwise, none of the items listed herein are under a hire purchase agreement. Furthermore, I attest that there are no other parties holding any claim or interest in the property mentioned.

  Sign

• Items and Value

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• Items and Value

• Items and Value

• Items and Value

• Items and Value

• Items and Value

• Items and Value

• Items and Value

• Items and Value

• Items and Value

• Items and Value

• Items and Value

• Media

  Media

• Media

  Media

• Media

  Media

• Media

  Media

• Media

  Media

• Media

  Media

• Media

  Media

• Media

  Media

• Yes

  No

  N/A