Claim DetailsBefore completing the form, please ensure you have read your documentation fully. We recommend you have the documentation to hand to help you complete the form. Note - the claim you are making may be subject to downward revision depending on the age of the item claimed for.Date of Incident*The date the incident first occurred Date Format: DD slash MM slash YYYY Policy NumberThe Unique Reference Number shown on your Policy ScheduleCustomer Name*Your First and Last Name as registered to the Policy or Warranty First Last Address*The address to which your Policy or Warranty is registered Street Address Address Line 2 City Region Postcode Telephone Number*Telephone Number and Area CodeMobile NumberTelephone Number and Area CodeEmail AddressA current e mail address by which we can contact you Is Your Claim Urgent?*YesNoWhy Is Your Claim Urgent?*Do you have children?*YesNoDo you have a vulnerability?*YesNoDate of Policy InceptionPolicy start date as listed on your Policy Schedule Date Format: DD slash MM slash YYYY Product Purchase DateThe date you first purchased the product Date Format: DD slash MM slash YYYY Product Purchase PriceThe cost of the product at the time of purchaseType of ApplianceWashing MachineTumble DryerDishwasherFridgeFreezerFridge-Freezer CombiAmerican-style Fridge FreezerMicrowaveExtractorHobGrillOvenCooker - CombinedWine CoolerTV - Flat ScreenTV - LCDFault Description*Please select from the dropdown list. Please also list any additional circumstances which you wish us to consider when processing your claim.Manufacturer*Manufacturer e.g. BoschModel/ Serial Number*The Unique Model / Serial Number listed on the appliance or in the manualItem ColourThe colour of the applianceIntegrated Appliance?YesNoAppliance Fuel TypeElectricGasBothPhotos Drop files here or Accepted file types: jpg, gif, png, pdf, docx, doc. Please add photos to support your submission, including proof of purchase, rating plate, model, and/or damage. Our file upload accepts .jpg, .gif, .png, .pdf, .docx and .doc files. Individual file size is limited to 16mb.DeclarationPlease check all your answers carefully before submitting your claim.Declaration* I hereby certify that all the information given in this form is truthful, accurate and complete. Dated Date Format: DD slash MM slash YYYY Please be aware that a fraudulent or exaggerated claim may result in a complete loss of any entitlement under the policy. Please note; Our privacy policy can be found here.EmailThis field is for validation purposes and should be left unchanged.
