Form name:
<div class="rounderCornerMiddle"> <div id="wrapper"> <div class="headerText"> HOUSE AND CONTENTS CLAIM FORM </div> <br /> <div> <strong>Issuance of this form is not to be taken as an admission of liability</strong> </div> <br /> <fieldset> <legend>Your Details </legend> <div class="itemField"> <div class="listDiv2"> Full name: </div> <div class="listDiv"> <input type="text" name="txbFullName" /></div> </div> <div class="itemField"> <div class="listDiv2"> Address: </div> <div class="listDiv"> <textarea name="txbAddress" rows="4" cols="22"></textarea></div> </div> <div class="itemField"> Contact details: </div> <div class="itemField"> <div class="listDiv2"> Postal Address: </div> <div class="listDiv"> <textarea name="txbPostalAddress" rows="4" cols="22"></textarea></div> </div> <div class="itemField"> <span class="blueBolderText">Telephone</span></div> <div class="itemField"> <div class="listDiv2"> Work: </div> <div class="listDiv"> <input type="text" name="txbWork" /></div> </div> <div class="itemField"> <div class="listDiv2"> Home: </div> <div class="listDiv"> <input type="text" name="txbHome" /></div> </div> <div class="itemField"> <div class="listDiv2"> Mobile: </div> <div class="listDiv"> <input type="text" name="txbMobile" /></div> </div> <div class="itemField"> <div class="listDiv2"> Email: </div> <div class="listDiv"> <input type="text" name="txbEmail" /></div> </div> </fieldset> <fieldset> <legend>CLAIM DETAILS </legend> <div class="itemField"> <div class="listDiv2"> Date/time of loss</div> <div class="listDiv"> <input type="text" name="txbDateOrTime" /></div> </div> <div class="itemField"> <div class="listDiv2"> Location of loss</div> <div class="listDiv"> <input type="text" name="txbLocation" /></div> </div> <div class="itemField"> <div class="listDiv2"> How did the loss happen? (Please provide full details). </div> <div class="listDiv"> <textarea name="txbDetails" cols="45" rows="5"></textarea></div> </div> <div class="itemField"> <div class="listDiv2"> Who caused the loss? Please provide names and addresses (if known). </div> <div class="listDiv"> <textarea name="txbCausedTheLoss" cols="45" rows="5"></textarea></div> </div> <div class="checkboxItemField"> <label> If burglary, theft or intentional damage, has a complaint been made to the police?</label> <input type="radio" name="rbtnTheft" value="Yes" /> <input type="radio" name="rbtnTheft" value="No" /> </div> <div class="itemField"> <span class="blueBolderText">If yes, please advise : </span> </div> <div class="itemField"> <div class="listDiv2"> Date reported</div> <div class="listDiv"> <input type="text" name="txbReported" /></div> </div> <div class="itemField"> <div class="listDiv2"> Complaint reference number</div> <div class="listDiv"> <input type="text" name="txbComplaintReference" /></div> </div> <div class="itemField"> <div class="listDiv2"> Name of the Police Officer</div> <div class="listDiv"> <input type="text" name="txbPoliceName" /></div> </div> </fieldset> <fieldset> <legend>DETAILS OF CLAIM</legend> <div class="itemField"> <table width="500" cellspacing="2" cellpadding="0" border="1"> <tbody> <tr> <th> Description of item </th> <th> Where obtained </th> <th> Date </th> <th> Repair Cost </th> <th> Replacement Cost </th> </tr> <tr> <td> <input type="text" name="txbDescription1" /> </td> <td> <input type="text" name="txbObtained1" /> </td> <td> <input type="text" name="txbDate1" /> </td> <td> <input type="text" name="txbRepairCost1" /> </td> <td> <input type="text" name="txbReplacement1" /> </td> </tr> <tr> <td> <input type="text" name="txbDescription2" /> </td> <td> <input type="text" name="txbObtained2" /> </td> <td> <input type="text" name="txbDate2" /> </td> <td> <input type="text" name="txbRepairCost2" /> </td> <td> <input type="text" name="txbReplacement2" /> </td> </tr> <tr> <td> <input type="text" name="txbDescription3" /> </td> <td> <input type="text" name="txbObtained3" /> </td> <td> <input type="text" name="txbDate3" /> </td> <td> <input type="text" name="txbRepairCost3" /> </td> <td> <input type="text" name="txbReplacement3" /> </td> </tr> <tr> <td> <input type="text" name="txbDescription4" /> </td> <td> <input type="text" name="txbObtained4" /> </td> <td> <input type="text" name="txbDate4" /> </td> <td> <input type="text" name="txbRepairCost4" /> </td> <td> <input type="text" name="txbReplacement4" /> </td> </tr> <tr> <td> <input type="text" name="txbDescription5" /> </td> <td> <input type="text" name="txbObtained5" /> </td> <td> <input type="text" name="txbDate5" /> </td> <td> <input type="text" name="txbRepairCost5" /> </td> <td> <input type="text" name="txbReplacement5" /> </td> </tr> </tbody> </table> </div> </fieldset> <fieldset> <div class="itemField"> If your property is lost or stolen, we may require proof of ownership. To assist in the settlement of such claims, could you please forward any receipts, credit card slips or other documents issued to you at the time of purchase.<br /> <br /> If possible, keep damaged items available for inspection. <br /> <br /> Willful or reckless exaggeration of the amounted claimed will end the policy, and the claim will not be paid. </div> </fieldset> <fieldset> <legend>YOUR PRIVACY</legend> <div class="itemField"> We collect and receive your personal information in this claim form to consider your claim. We hold it. You have rights to access it, and correct it under the Privacy Act 1993. <br /> <br /> You must provide your relevant personal information to us to comply with the Claims Conditions of this policy. If you fail to do so, we may decline your claim. <br /> <br /> We obtain your authority below to transfer your relevant personal information to other members of the insurance industry (including Insurance Claims Register Limited), financially interested parties noted on your policy, and repairers</div> </fieldset> <fieldset> <legend>YOUR DECLARATION</legend> <div class="itemField"> <span class="blueBolderText">I declare that:</span> <br /> <ul> <ol> 1 All information given to New India in connection with the claim is true.</ol> <ol> 2 No information relevant to the claim has been omitted.</ol> <ol> 3 I authorize:</ol> <ul> <ol> 3.1 New India to disclose this information to:</ol> <ul> <ol> 3.1.1 Other members of the insurance industry (including Insurance Claims Register Limited), and</ol> <ol> 3.1.2 Financially interested parties noted on the policy, and</ol> <ol> 3.1.3 Parties repairing or replacing your property.</ol> </ul> <ol> 3.2 The disclosure of my personal information held by any other parties to New India for the purpose of considering and administering the claim.</ol> </ul> </ul> </div> </fieldset> </div> </div>