Were the premises occupied at the time? Yes No If not, when were they last occupied? 3 Insurance – 3BUSection If there is another insurance policy that covers the same property please give the details below. Name of insurance company Address of insurance company Policy number 4 Previous Claims – 4BUSection Please provide details of any claims made on the property within the last 5 5 - Declarations 5BUSection I/We declare that the statements contained within this document are true to the best of our/my knowledge and belief and I/we claim the amount above in respect of the items mentioned. I/We understand that Insurers and other agents share information with each other to prevent fraudulent claims via the Claims Underwriting Exchange (CUE) operated by Insurance Databases Services Ltd. A list of participants is available. The information supplied on this form, together with the information supplied at proposal stage, and other information relating to the claim will be made available to the participants. By signing below, I/we understand that this information may be sought from other insurers to verify the statements made in this claim form, and that the issue of this form should not be construed as an admission of liability on behalf of the insurer. If you require further clarification of this disclosure, please e-mail us at or telephone/fax us on 023 9224 8770 / 023 9224 8799. HH Information 6BUImportant Please note that the Policyholder will not be indemnified in respect of 2. Loss or destruction of the Insured property as a result of movement of solid the following - floor slabs 1. Loss or destruction of or damage to the Insured property caused by 3. The policy excess as stated in the Schedule of Insurance. (a) collapse, cracking, shrinking or settlement of any buildings Other policy exclusions apply. For details of these, please refer to the policy (b) coastal or river erosion documents. (c) defective design or inadequate construction of foundations (d) demolition, structural alteration or repair (e) settlement or movement of the ground
Were the premises occupied at the time? Yes No If not, when were they last occupied? 3BUSection 3 – Insurance If there is another insurance policy that covers the same property please give the details below. Name of insurance company Address of insurance company Policy number 4BUSection 4 – Previous Claims Please provide details of any claims made on the property within the last 5 5BUSection 5 - Declarations I/We declare that the statements contained within this document are true to the best of our/my knowledge and belief and I/we claim the amount above in respect of the items mentioned. I/We understand that Insurers and other agents share information with each other to prevent fraudulent claims via the Claims Underwriting Exchange (CUE) operated by Insurance Databases Services Ltd. A list of participants is available. The information supplied on this form, together with the information supplied at proposal stage, and other information relating to the claim will be made available to the participants. By signing below, I/we understand that this information may be sought from other insurers to verify the statements made in this claim form, and that the issue of this form should not be construed as an admission of liability on behalf of the insurer. If you require further clarification of this disclosure, please e-mail us at HH or telephone/fax us on 023 9224 8770 / 023 9224 8799. 6BUImportant Information Please note that the Policyholder will not be indemnified in respect of the following - 1. Loss or destruction of or damage to the Insured property caused by (a) collapse, cracking, shrinking or settlement of any buildings (b) coastal or river erosion (c) defective design or inadequate construction of foundations (d) demolition, structural alteration or repair (e) settlement or movement of the ground 2. Loss or destruction of the Insured property as a result of movement of solid floor slabs 3. The policy excess as stated in the Schedule of Insurance. Other policy exclusions apply. For details of these, please refer to the policy documents.
Broker-Subsidence-Claim-Form-13.11.17.docx