DISASTER CLAIM FORM

If you have suffered damages in the recent disaster, please notify us of your claim by completing and submitting the form below

• Date of Loss:*
  
  
• Name of insured*
• Name of person submitting the notification if different from the name of insured
• Policy Number(s).: (Please list all applicable policy #s)(Please list all applicable policy #s)
• Phone*
• Other Phone Number
• Email*
  
• Physical address of your property*
• Please select all that applies to you:*
  • 
    I incurred damage to my building/home as a result of the volcanic eruption
  • 
    I incurred damage to my contents as a result of the volcanic eruption
  • 
    I incurred damage to my vehicle as a result of the volcanic eruption
• Please describe what type of loss/damage you have suffered*
• Is your asset covered by any other insurance*
  • Yes
  • No
• What is the name of the other insurer and what is the value of the insurance?*
• When was the last time that the property was occupied prior to the loss?*
• Was the property being used for Private or Commercial purposes?*
  • Yes
  • No
• Have actions been taken to mitigate or lessen the damages?*
  • Yes
  • No
• Please provide details of the actions you have taken
• Please upload any pictures you may have of the damage suffered/ incurred
• 
  Drop files here or
  
  Accepted file types: jpg, gif, png, pdf.
• Please upload any estimate or repair quotation you may have obtained
• 
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  Accepted file types: jpg, gif, png, pdf.

• VERY IMPORTANT – FRAUDULENT AND EXAGGERATED CLAIMS

  The above answers to our questions will be the basis of consideration of your claim. You must ensure that all information is true and correct to the best of your knowledge and belief, and that all material facts have been disclosed. 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 it.
  FAILURE TO DO THIS MAY MEAN THAT YOUR POLICY BECOMES INVALID AND A CLAIM PAYMENT WILL NOT BE MADE.

• DECLARATION*
  • 
    I/We declare the foregoing particulars to be correct according to my information and belief. I/We understand that you may seek information from other insurers to check the answers I/we have provided. – Make it mandatory for them to click a button to confirm this.
• File
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  Accepted file types: jpg, gif, png, pdf.
• CAPTCHA