Cover4Insurance Claims Service Claim Form

Cover 4 Insurance Claims Services

Contact Us: 0161 974 1101

Policy Details

Policy Type (Please upload your Policy Schedule when submitting your claim form)

Master Policy Number (if applicable)

( If your university is not on the list please revisit the main website for contact information )

Have you purchased any Optional Extensions?*

Block policies

To verify your insurance you must provide a copy of the schedule of insurance provided when you purchased the optional extensions.

Policy Number (input number)

Policy Number

Policy Number (input number)

University / Accommodation Provider (if applicable)

Policy Holder Details

First Name*

Middle Name: (Or Initial)

Surname*

Date of Birth:*

First Name: (Additional Insured)

Middle Name: (OR Initial)

Surname:

Date of Birth:

TELEPHONE No 1 (preferred contact no’)*

TELEPHONE No 2

Email Address 1: (preferred email address)

Email Address 2:

INSURED ADDRESS (For Example, Term Time Address)

Address Line 1*

Address Line 2

Address Line 3

City/Town

Postcode*

Country

HOME ADDRESS (IF DIFFERENT)- add heading

Address Line 1

Address Line 2

Address Line 3

City/Town

Postcode

Country

DETAILS OF YOUR CLAIM

Type of Claim:

Type of theft/attempted theft

WHERE DID THE INCIDENT OCCUR?

Date*

Time*

: HH

MM

WHO DISCOVERED THE INCIDENT?

Date

Time

: HH

MM

WHERE WERE YOU AT THE TIME OF THE INCIDENT?

WERE THE PREMISES OCCUPIED AT THE TIME OF THE INCIDENT?

IF YES, BY WHO?

IF NO, WHEN WAS THE PREMISES LAST OCCUPIED?

WHO LAST OCCUPIED THE PREMISES?

IF YOU ARE CLAIMING FOR THEFT FROM A BUILDING, HOW AND WHERE WAS ENTRY GAINED?

HAS THE INCIDENT BEEN REPORTED TO THE UNIVERSITY ACCOMMODATION OFFICE/SECURITY?

If no, Please confirm why?

WERE THE PREMISES DAMAGED BY ENTRY OR EXIT? IF SO, PLEASE PROVIDE DETAILS

DO YOU HAVE ANY OTHER INSURANCE COVERING THE LOSS? IF YES, PLEASE PROVIDE FURTHER DETAILS

NAME OF INSURER

POLICY NUMBER

IS THE INSURED ADDRESS OCCUPIED SOLELY BY YOU?

IF NO, PLEASE PROVIDE FURTHER DETAILS BELOW

NAME(S) OF OTHER RESIDENT(S)	DID THEY SUFFER A LOSS? YES/NO	AMOUNT	ARE THEY INSURED SEPARATELY?	IF YES, PLEASE PROVIDE THE INSURER NAME

DETAILS OF INCIDENT*

PLEASE PROVIDE FULL DETAILS OF THE CIRCUMSTANCES LEADING UP TO AND SURROUNDING THE INCIDENT, AND ITS DISCOVERY

DETAILS OF POLICE SECURITY REPORT

BEFORE SUBMITTING THIS FORM, PLEASE ENSURE THAT ALL THEFT OR MALICIOUS DAMAGE CLAIMS ARE REPORTED TO THE POLICE.

WAS THE INCIDENT REPORTED TO THE POLICE?

Date

Time

: HH

MM

Was the incident reported to the university/accommodation office and security?

Please provide a reference number

Please explain why not reported to the accommodation/security office

HOW WAS THE REPORT MADE?

WAS THE REPORT MADE AS

Police Station Address Line 1

Address Line 2

Address Line 3

City/Town

Postcode

Country

Telephone of Police Station

Police Crime Reference Number

DETAILS OF ITEMS LOST, STOLEN OR DAMAGED

DESCRIPTION OF ITEMS	MAKE, MODEL & SERIAL NUMBER	DATE OF PURCHASE	WHERE PURCHASED OR FROM WHOM?	ORIGINAL COST PRICE	CURRENT COST PRICE

TOTAL AMOUNT CLAIMED

Total amount original cost

Total current costs

CLAIMANT DECLARATION

HAVE YOU EVER BEEN CONVICTED OR DO YOU HAVE A CONVICTION PENDING FOR FRAUD, THEFT OR OTHER DISHONESTY?

I DECLARE THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
I UNDERSTAND THAT ANY MISSTATEMENTS OR WITHOLDING OF INFORMATION WILL RENDER MY CLAIM VOID AND MAY LEAD TO CRIMINAL PROCEEDINGS AGAINST ME.
I HAVE NOT WITHELD ANY INFORMATION CONNECTED WITH THIS INCIDENT AND AGREE TO PROVIDE ANY FURTHER INFORMATION OR DOCUMENTATION AS MAY BE REQUIRED.
I AGREE THAT THE INSURER SHALL HAVE ABSOLUTE DISCRETION IN THE CONDUCT OF ANY PROCEEDINGS OR SETTLEMENTS OF ANY CLAIMS AGAINST ME ARISING OUT OF THIS INCIDENT
I UNDERSTAND THAT THE INSURER DOES NOT ADMIT ANY LIABILITY BY THE ISSUE OF THIS FORM

SIGNED BY THE INSURED*

Date*

SIGNED BY THE CLAIMANT (IF DIFFERENT)

Date

WHAT TO DO NEXT

Please attach your Policy Schedule and/or Master Policy Schedule (if applicable) and any supporting documentation in the Document Upload section.

IMPORTANT: PLEASE ENSURE THAT YOU INCLUDE ANY PROOF OF PURCHASE / OWNERSHIP DOCUMENTATION (SUCH AS PURCHASE RECEIPTS, GUARANTEE CERTIFICATES, INVOICES ETC…. ), FOR ANY ITEMS BEING CLAIMED FOR WHERE POSSIBLE.

DOCUMENT UPLOAD

File

Drop files here or

DATA PROTECTION MANDATE

I hereby consent to my student accommodation provider sharing any of my relevant data in connection with my insurance claim to Stream Claims Services on behalf of Claims Consortium Group, who will use the information only for the purposes of the assessment of the insurance claim referenced above. I also acknowledge that without this information, Stream Claims Services will be unable to progress my claim

Full name*

Date*

Policy Details

Policy Holder Details

INSURED ADDRESS (For Example, Term Time Address)

HOME ADDRESS (IF DIFFERENT)- add heading

DETAILS OF YOUR CLAIM

DETAILS OF POLICE SECURITY REPORT

CLAIMANT DECLARATION

WHAT TO DO NEXT

DOCUMENT UPLOAD

DATA PROTECTION MANDATE

CLAIMS HELPLINE: 0161 974 1101