Miscellaneous Claim Form PROCESSING YOUR CLAIM Name of Insured Policy Number Address Street Address City Contact Person Telephone Number Email Address* Premises where the Loss was sustained Date of Loss Time of Loss Type/Nature of claim Give FULL details of how the loss or damage occurred In the case of a loss please give date and time the property was last seen When was the loss or damage discovered and by whom? If you employ the services of a Security company please provide the name+ Have they investigated the loss? Have the Police been informed? Which Station? Date and time of the report What is the CR Ref. No? Name of person making the report If the item has been damaged can it be repaired Have you found a repairer? Name of repairer Telephone Number I/We hereby declare that the information hereon to be true and correct in every respec t and that I/We have not withheld any material information from the Insurers which could effect their acceptance of this claim. Designation/ Title (if applicable) PROCESSING YOUR CLAIM It will certainly assist us in processing your claim promptly if all of the information required below is provided DESCRIPTION OF PROPERTY LOST OR DAMAGED WHERE PURCHASED OR ACQUIRED WHEN PURCHASED OR ACQUIRED COST OF REPLACEMENT DEDUCTION FOR DEPRECIATION/ WEAR AND TEAR NET AMOUNT BEING CLAIMED REMARKS (IF ANY) I hereby certify that the information in this claim form is true and correct to the best of my knowledge and belief. I authorize Champions Insurance Company to process the claim based on the information provided.