Claim form v2 (smarter validation)

1. Your Details (Individual and/or organisation submitting the claim)

Title*

Name*

Surname*

Organisation (if applicable)

Address

Postcode*

Contact Number (9am-5pm)*

Email*

Policy Number*

Date Insurance Purchased*

2. Claim Type

Is the claim for - *
Theft (Complete sections 3, 5, 6, 7 and 8) orDamage (Complete sections 4, 5, 6, 7 and 8)

3. Theft Claims

Date of theft*

Time of theft*

Date theft discovered*

Time theft discovered*

Date when equipment was last seen*

Time when equipment was last seen*

Who was in charge of the equipment when the theft occurred?*

Where did the theft occur?*
HomeSchool, college etc.WorkTravellingOther

Please provide further details, e.g equipment stolen from the lounge*

How did the theft occur?*

Where were you located when the theft occurred?*

If the theft was from your premises or vehicle, how was access gained? (please provide as much details as possible)

Date reported to the police*

Time reported to the police*

Police references*

Police station address including postcode*

Police station telephone number

Name of the individual who you reported the theft to

4. Damage Claims

Date of incident*

Time of incident*

Date of discovery*

Time of discovery*

Who was in charge of the equipment when the incident occured?*

What type of incident occured? (tick all that apply)*
Dropped equipmentFell whilst carrying equipmentFire damage to equipmentHeat damage to equipmentItem fell on equipmentItem shut inside equipmentKnocked off furnitureKnocked out of handsLiquid spillageNo incident took placePet damagePower surge to equipmentSat on equipmentSmoke damage to equipmentStood on equipmentOther (please give details)

Where "other" has been selected, please provide details

What type of damage occurred? (tick all that apply)*
Casing damageCracked screenDamage to portsEquipment in piecesEquipment not chargingEquipment scratchedEquipment will not startLiquid spillage to keyboardLiquid spillage to screenScreen display affectedOther (give details)

Where "other" has been selected, please provide details

How did the incident occur? (please provide as much detail as possible)*

Where were you located when the incident occurred?*

Name of any person excluding the claimant, who you feel is responsible for the incident

Did anyone else witness the incident?
yesno

If yes, please provide their name and contact details

When the incident occurred was the equipment in a case?*
yesno

If yes, please provide make and model

5. Other Insurances

Do you have any other insurance that may cover this incident?*
yesno
Please provide the insurance company and policy number

6. VAT Status

Are you a taxable organisation for VAT purposes and can you recover VAT?*
yesno

If yes, the VAT element of the cost of repair or replacement will be invoiced directly to you by the company authorised to fulfil your claim.

7. Declaration

The details you supply will be used to administer your claim and to combat fraud. The answers to the questions will be the basis of the assessment of your claim. All material facts must be disclosed. A material fact is one that is likely to influence us in the assessment or acceptance of this claim, or one that is likely to influence our consideration of cover under the terms of your policy. If you are in any doubt as to whether a fact is material, you must disclose it. I/We submit my/our claim for the amounts stated and declare that, to the best of my/our knowledge and belief, all information given on this form is true and correct, as will be my/our response to any further enquiries made by compucover.

Please tick the box to confirm you have read the declaration*

Please ensure you complete the equipment details below

8. Details of items stolen or damaged

Item 1

Make*

Full Model Description*

Colour

Serial Number*

IMEI (where applicable)

Date Purchased*

Where Purchased*

Purchase Price (inc. VAT)

+ Item 2

Make*

Full Model Description*

Colour

Serial Number*

IMEI (where applicable)

Date Purchased*

Where Purchased*

Purchase Price (inc. VAT)

+ Item 3

Make*

Full Model Description*

Colour

Serial Number*

IMEI (where applicable)

Date Purchased*

Where Purchased*

Purchase Price (inc. VAT)

+ Item 4

Make*

Full Model Description*

Colour

Serial Number*

IMEI (where applicable)

Date Purchased*

Where Purchased*

Purchase Price (inc. VAT)

+ Item 5

Make*

Full Model Description*

Colour

Serial Number*

IMEI (where applicable)

Date Purchased*

Where Purchased*

Purchase Price (inc. VAT)

9. Additional Information

If you have any additional information that will assist us with your claim, please include details below