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 - must be dd/mm/yyyy format * REQUIREDThe date the incident first occurred Date Format: DD slash MM slash YYYY Policy NumberThe Unique Reference Number shown on your Policy ScheduleCustomer Name * REQUIRED FirstYour First and Last Name as registered to the Policy or Warranty Last Address * REQUIRED Street AddressThe address to which your Policy or Warranty is registered Address Line 2 City Region Postcode Telephone Number * REQUIREDTelephone Number and Area CodeMobile NumberTelephone Number and Area CodeEmail AddressA current e mail address by which we can contact you Is Your Claim Urgent? * REQUIREDYesNoWhy Is Your Claim Urgent? * REQUIREDDo you have children? * REQUIREDYesNoDo you have a vulnerability? * REQUIREDYesNoDate of Policy Inception - must be dd/mm/yyyy formatPolicy start date as listed on your Policy Schedule Date Format: DD slash MM slash YYYY Product Purchase Date - must be dd/mm/yyyy formatThe 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 * REQUIREDPlease select from the dropdown list. Please also list any additional circumstances which you wish us to consider when processing your claim.Manufacturer * REQUIREDManufacturer e.g. BoschModel/ Serial Number * REQUIREDThe Unique Model / Serial Number listed on the appliance or in the manualItem ColourThe colour of the applianceIntegrated Appliance?Is the item built into the units surrounding it?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.Maximum file size - 16 mega bytes. DeclarationPlease check all your answers carefully before submitting your claim.Declaration * REQUIRED I hereby certify that all the information given in this form is truthful, accurate and complete. Dated - must be dd/mm/yyyy format 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.CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
