Assign a claim

Please complete and submit the following form: NOTE: If you are attaching a claim report for submission then initial fields need not be completed. You must include an e-mail address. Click ‘Browse’ then select the file you wish to attach.

Instructing Party:

Reference Number:

Insured:

Insured Company:

Location of Incident

Country:

City:

Date of Incident (DD/MM/YYYY):

Time of Incident:

Description of Incident:

Estimated Amount of Loss:

Notes / Instructions:

Contact Name:

Company Name:

Contact Telephone Number:

Submit Attachment(s)

You MUST include an e-mail address. [Click Browse then select file to attach.] You cannot submit an attachment without including your e-mail address.

File 1

File 2

File 3

File 4

You MUST include an e-mail address to submit this form.

Contact e-mail Address: