We have made our claims process as straightforward as possible to ensure that you are reunited with your repaired or replacement equipment as quickly as possible. Therefore please complete this claim form in full. Your claim will be delayed if you do not complete ALL relevant sections. All claims must be referred to the Claims Administrators before you take any action. Failure to do so will invalidate your claim. For a claim that is not capable of repair e.g. following theft, the Claims Administrators will instruct our authorised supplier to arrange replacement. The claim form will need to be completed in full by the named Policyholder. If the Policyholder requires someone else to complete the form on their behalf, then due to the GDPR – General Data Protection Regulation we will need the name and address of the person who will complete the form on the Policyholder’s behalf. This information will need to be provided by the Policyholder in writing either by post or e-mail. I am a Key Worker, please prioritise my claim. During the Covid-19 outbreak MB&G would like to help by prioritising claims received from those deemed “Key Workers”. If you fit this category, please check the tick box. Proof of your status as a key worker will be required.Your DetailsName FirstYour First and Last Name as registered to the Policy Last Organisation (if applicable)The organisation as registered to the PolicyAddress * REQUIRED Street AddressThe address to which your Policy is registered Address Line 2 City Region Postcode Contact Number (9am-5pm) * REQUIREDEmail * REQUIREDThe e mail address to which your Policy is registered Policy Number * REQUIREDThe Unique Reference Number shown on your Policy ScheduleDate insurance purchased - must be dd/mm/yyyy format * REQUIREDThe date as listed on your Policy Schedule Date Format: DD slash MM slash YYYY Claim TypeIs the claim for: * REQUIREDPlease select one optionTheft/ LossDamageTheft/ Loss ClaimsDate of theft/ loss - must be dd/mm/yyyy format * REQUIREDThe date the theft / loss occurred Date Format: DD slash MM slash YYYY Time of theft/ loss * REQUIREDThe time the theft / loss occurred : HH MM AM/PM AM PM Date theft/ loss discovered - must be dd/mm/yyyy format * REQUIREDThe date you very first noticed the theft / loss Date Format: DD slash MM slash YYYY Time theft/ loss discovered * REQUIREDThe time you very first noticed the theft / loss : HH MM AM/PM AM PM Date the equipment was last seen - must be dd/mm/yyyy format * REQUIREDThe date you last saw the equipment Date Format: DD slash MM slash YYYY Time the equipment was last seen * REQUIREDThe time you last saw the equipment : HH MM AM/PM AM PM Who was in charge of the equipment when the theft/loss occurred * REQUIREDFull name of individual responsibleWhere did the theft/loss occur * REQUIREDFull location of where the loss occurredHomeSchool, college, etcWorkTravellingOtherPlease provide further details * REQUIREDe.g. equipment stolen from the loungeHow did the theft/loss occur * REQUIREDplease explain the circumstance surrounding the theft / loss eg “Gadget was dropped and broke”Where were you located when the theft/loss occurred * REQUIREDYour location at the time of lossIf the theft was from your premises or vehicle, how was access gainedPlease provide as much detail as possible.If the incident was reported to the police please fill in the details below, for theft claims, this information MUST be provided, failure to do so may delay your claim.Date reported to the police - must be dd/mm/yyyy format Date Format: DD slash MM slash YYYY Time reported to the police* : HH MM AM/PM AM PM Police referenceThe unique crime reference number as issued by the PolicePolice station address Street AddressThe address of the constabulary the theft has been reported to Address Line 2 City Region Postcode Police station telephone numberThe telephone number of the constabulary the theft has been reported toName of the individual who you reported the theft/loss toFull name of the individual at the Police Station who you reported the theft / loss toDamage ClaimsDate of incident - must be dd/mm/yyyy format * REQUIREDThe date the incident arising to the loss occurred Date Format: DD slash MM slash YYYY Time of incident * REQUIREDThe time the incident arising to the loss occurred : HH MM AM/PM AM PM Date incident discovered - must be dd/mm/yyyy format * REQUIREDThe date the incident arising to the loss was discovered Date Format: DD slash MM slash YYYY Time incident discovered * REQUIREDThe time the incident arising to the loss was discovered : HH MM AM/PM AM PM Who was in charge of the equipment when the incident occurredFull name of individual responsibleWhat type of incident occurred * REQUIREDCtrl+click to select more than one optionDropped equipmentFell whilst carrying equipmentFire damage to equipmentHeat damage to equipmentItem fell on equipmentItem shut inside equipmentKnocked off furnitureKnocked out of handsLiquid spillageNo incident took placePet damagePower surge to equipmentSat on equipmentSmoke damage to equipmentStood on equipmentWhat type of damage has occurred * REQUIREDCtrl+click to select more than one optionCasing damageCracked screenDamage to portsEquipment in piecesEquipment malfunctioningEquipment not chargingEquipment scratchedEquipment will not startLiquid spillage to screenScreen display affectedHow did the incident occur * REQUIREDPlease provide as much detail as possibleWhere were you located when the incident occurred * REQUIREDYour location at the time of lossName of any person excluding the claimant, who you feel is responsible for the incidentFull name of individual responsibleIf another person is responsible for the incident, how were they responsiblePlease explain the circumstanceDid anyone else witness the incident * REQUIREDPlease select oneYesNoPlease provide their name and contact detailsFull Name, Address, E mail and Telephone Number if availableWhen the incident occurred was the equipment in a case * REQUIREDPlease select oneYesNoPlease provide the make and modelAs listed on the appliance literaturePlease provide photographs of the device Drop files here or Accepted file types: jpg, gif, png, pdf. Maximum file size - 8 mega bytes. Other InsurancesDo you have other insurance that may cover this incident * REQUIREDPlease select oneYesNoPlease provide the insurance company and policy number * REQUIREDName, Address and Unique Reference NumberVAT StatusAre you VAT registered * REQUIREDPlease select oneYesNoPlease confirm your VAT number * REQUIREDUnique VAT Number as issued by HMRCDeclarationThe details you supply will be used to administer your claim and to combat fraud. The answers to the questions will be the basis of the assessment of your claim. All material facts must be 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.I/We submit my/our claim for the amounts stated and declare that, to the best of my/our knowledge and belief, all information given on this form is true and correct, as will be my/our response to any further enquiries made by CompuCover.Confirmation * REQUIRED Please tick the box to confirm you have read the declaration Details of items stolen or damagedItem details: * REQUIREDMakeModelColourSerial NoDate PurchasedWhere PurchasedPurchase Price (inc VAT)Last Date of Usage Additional InformationIf you have any additional information that will assist us with your claim, please include details belowCAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.