claim form - compucover

1 Suite 2, Bloxam Court, Corporation Street, Rugby, Warwickshire CV21 2 DUTelephone: 01788 563111 E-mail: To ensure your claim is dealt with as quickly as possible, please complete this form in full, sign where indicated and return it claim will be delayed if you do not complete ALL relevant claims must be referred to the Claims Administrators before you take any action. Failure to do so will invalidate your a claim that is not capable of repair following theft the Claims Administrators will instruct our authorised supplier to arrange : claim form1 - YOUR DETAILSF irstname:Surname:Organisation(if applicable):Address:Postcode:Is the claim for:-Complete sections 3,5,6,7 and 82 - claim TYPEC omplete sections 4,5,6,7 and 8 Theft/LossDamageDate and time of theft/loss:3 - THEFT/LOSS CLAIMSDate and time the equipment was last seen:Page 1 of 5 Date and time theft/loss discovered:Who was in charge of the equipment when the theft/loss claim form will need to be completed in full by the named Policyholder.

2 If the Policyholder requires someone else to complete the form on their behalf, then due to the GDPR - General Data Protection Regulation we will need the name and address of the person who will complete the form on the Policyholder's behalf. This information will need to be provided by the Policyholder in writing either by post, fax or Number (9am-5pm):Date insurance purchased:E-mail:Policy Number:PLEASE DO NOT SEND YOUR EQUIPMENT TO USHomeSchool, college did the theft/loss occur:WorkTravellingOtherPlease provide further details, equipment stolen from the lounge:How did the theft/loss occur:Where were you located when the theft/loss occurred:If the theft was from your premises or vehicle, how was access gained (please provide as much detail as possible):(Individual and/or organisation submitting the claim )3 - THEFT/LOSS CONTINUEDDate and time reported to the police:Police reference:Police station address including postcode.

3 4 - DAMAGE CLAIMSP olice station telephone number:Name of the individual who you reported the theft/loss to:How did the incident occur (please provide as much detail as possible):Page 2 of 5 Date and time of incident:Date and time of discovery:Who was in charge of the equipment when the incident occurred:HomeSchool, college did the incident occur:WorkTravellingOtherWhere exactly did the incident occur, in the lounge, classroom etc:Dropped equipmentFell whilst carrying equipmentWhat type of incident occurred (tick all that apply):Item shut inside equipmentFire damage to equipmentHeat damage to equipmentItem fell on equipmentKnocked off furnitureKnocked out of handsLiquid spillageNo incident took placePet damagePower surge to equipmentSat on equipmentSmoke damage to equipmentStood on equipmentOther (give details)Casing damageCracked screenWhat type of damage occurred (tick all that apply).

4 Equipment not chargingDamage to portsEquipment in piecesEquipment malfunctioningEquipment scratchedEquipment will not startLiquid spillage to keyboardLiquid spillage to screenScreen display affectedOther (give details)(Please ensure all data is backed up prior to collection of your equipment)If the incident was reported to the police please fill in the details below, for theft claims this information MUST be provided,failure to do so may delay your you have any other insurance that may cover this incident:YesNoIf yes, please provide the insurance company and policy number:When the incident occurred was the equipment in a case:The details you supply will be used to administer your claim and to combat fraud. The above answers to the questions will be the basis of the assessment of your material facts must be disclosed.

5 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 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 - DAMAGE CONTINUED7 - DECLARATION5 - OTHER INSURANCESP lease tick the box to confirm you have read the declarationSigned:Date:PLEASE ENSURE YOU COMPLETE THE EQUIPMENT DETAILS OVERLEAFPage 3 of 56 - VAT STATUSAre you VAT registered: Yes NoIf yes to the above, can you please confirm your VAT number:(Please ensure all data is backed up prior to collection of your equipment)YesNoDid anyone else witness the incident.

6 If yes, please provide their name and contact details:YesNoIf yes, please provide the make and model:Name of any person excluding the claimant, who you feel is responsible for the incident:Where were you located when the incident occurred:If another person is responsible for the incident, how were they responsible:Item8 - DETAILS OF ITEMS STOLEN OR DAMAGEDMakeFull Model DescriptionIMEI (if applicable)ColourDatePurchasedWherePurch asedPurchasePrice (inc VAT)12345678910 Page 4 of 5 Serial NumberPage 5 of 5 April 20189 - ADDITIONAL INFORMATION If you have any additional information that will assist us with your claim , please include details below.