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

Contact e-mail address:

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