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Home
About
Products
Claims
- Download/Submit Forms
Get A Quote
Contact
Sign in / Join
Toggle website search

Water Loss Claim

Please complete the form below

Water Loss Claim

Insurer

Claim Number *

Account Number *

Connection Number *

Details

Metre Reading Immediately After Repairs *

Date Of Repairs *

Account Holders Name *

Identity Number *

Postal Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Contact Number *

Address Were Loss Occurred

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Description Of Dwelling *

Private Dwelling
Block Of Flats
Duplex / Simplex

If More Than 2 of The Above Are Applicable, Does Each Unit Have Its Own Water Meter *

Yes
No

Date Water Leak Was Repaired *

Name Of Plumber / Contractor *

Plumber's / Contractor Contact Number *

State Briefly The Circumstances Of Loss *

Was Loss Caused By Another Party *

Yes
No

Name Of Party Responsible For Loss *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Contact Number *

Have You Had Any Previous Claims *

Yes
No

Date Of Previous Claim *

Do You Have A Bond On The Property *

Yes
No

Name Of Bond Holder *

Account Number *

Do You Have Any Building / Content Insurance *

Yes
No

Name Of Insurance *

Policy Number *

By Submitting This You Hereby Declare That The Foregoing Particulars Are Correct In Every Respect *

I Agree

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