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Customer Info
Insured's Name
*
Broker Reference
Policy Number
Insured's Address
*
Address 1
Address 2
City
County
Post Code
My correspondence address is not the same as the park address
Park Name
Park Address
Address 1
Address 2
City
County
Post Code
Insured's Email
Insured's Contact Number
Details of Property
Make
Model
Age
Pitch Number
Are you Registered for VAT?
Yes
No
VAT Registration Number
Bank Details for Settlement
Sort Code
Account Number
Account Number
Circumstances of Claim/Loss
Date & Time of Loss/Damage
Location
State Fully how Loss/Damage Occured
In the Case of Theft/Malicious or Accident Loss
Crime Reference Number
Date Reported
Police Station Address
Street Address
Address Line 2
City
County
Postcode
Description of items for which you are claiming
(Including Make and Model No where appropriate) Please supply photos of any relevant documentation to support your claim I.e. Purchase receipts, manuals, estimates, invoices. Continue on separate sheet if necessary
I Need to Claim for 5 or More Items
Please
Download the Claim Document
and fill it out to your full extent and upload to the shown field.
Completed Document Submission
Max. file size: 128 MB.
Item 1
Details/Description of property Lost/ Damaged/Destroyed
Please supply make and model of electrical equipment
Date when Bought
DD slash MM slash YYYY
Original Purchase Price
Cost to Replace or Repair
Value of Salvage
Amount Claimed
Item 2
Details/Description of property Lost/ Damaged/Destroyed
Please supply make and model of electrical equipment
Date when Bought
DD slash MM slash YYYY
Original Purchase Price
Cost to Replace or Repair
Value of Salvage
Amount Claimed
Item 3
Details/Description of property Lost/ Damaged/Destroyed
Please supply make and model of electrical equipment
Date when Bought
DD slash MM slash YYYY
Original Purchase Price
Cost to Replace or Repair
Value of Salvage
Amount Claimed
Item 4
Details/Description of property Lost/ Damaged/Destroyed
Please supply make and model of electrical equipment
Date when Bought
DD slash MM slash YYYY
Original Purchase Price
Cost to Replace or Repair
Value of Salvage
Amount Claimed
Additional Policies
Do you hold any other policies that may cover this type of loss
Yes
No
(Home Contents or Travel Insurance)
Name of Insurer
Policy Number
Insurer Address
Street Address
Address Line 2
City
County
Postcode
Accountability
Do you hold any other party to be responsible for the loss/damage?
Yes
No
Name of Person / Persons Responsible
Address (if known)
Street Address
Address Line 2
City
County
Postcode
Name of Insurer
Policy Number
Insurer Address
Street Address
Address Line 2
City
County
Postcode
Witnesses
Is there anyone else who has knowledge on / has witnessed the event?
Yes
No
Name
Contact Number
Witness Address
Street Address
Address Line 2
City
County
Postcode
Other Information
Who should any settlement cheques (If applicable) be made out to?
Declaration
*
I/We understand that you will pass the information on this form, and about any incident of which I/we may give details, to IDS Ltd so that they can make it available to other insurers. I/We also understand that, in response to any searches you may make in connection with this application or any incident of which I/we have given details, IDS Ltd may pass you information it has received from other insurers about other incidents involving anyone insured under the policy. I/We understand that you may ask for information from other insurers to check the answers I/we have provided. I/We confirm that, as far as I am/we are aware, the statements made by me/us or on my/our behalf in connection with the insurance are true and complete. I/We agree to accept a policy in the Company’s usual form for this class of business. I/We authorise Parksure, a trading Style of Cass-Stephens Insurances to handle the claim of behalf of the Insurers.
Claims and Underwriting Exchange
Insurers pass information to the Claims and Underwriting Exchange Register run by Insurance Database Services Ltd (IDS Ltd). The aim is to help us to check information provided and also to prevent fraudulent claims. When we deal with your request for insurance, we may search the register. When you tell us about an incident (such as a fire, water damage or theft) which may or may not give rise to a claim, we will pass information relating to it to the register. You can ask us for more information about this. You should show this notice to anyone who has an interest in property insured under the policy.
Date
DD slash MM slash YYYY
Signature
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