CHURCH AND COMMERCIAL PROPERTY CLAIM FORM

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1 Methodist Insurance plc Brazennose House, Brazennose Street, Manchester M2 5AS Telephone Facsimile CHURCH AND COMMERCIAL PROPERTY CLAIM FORM CLAIM NUMBER: (Office use only) Please read this information carefully before completing the Claim Form. 1. Please complete ALL relevant sections of this claim form, before signing the declaration and returning it to us at the above address. There is a different claim form for personal injury claims or damage to third party property. Please telephone our offices if you require a Liability Report and Personal Accident Claim Form or are unsure which form you need to complete. 2. Please read the form in conjunction with your policy wording and policy schedule, which will help explain exactly what cover is in force. The policy wording will also assist you in how to make a claim. 3. If you have any problems completing this form or wish to discuss your claim in any way, please do not hesitate to telephone us for assistance, on , between 9am and 5pm Monday to Friday. Section A Insured s Details Policy Number: (This must be quoted) Full name of Insured: Full address of the property insured, including postcode: Name and address to which correspondence should be sent, including postcode (Only if different from above): Daytime telephone number: Fax number: address: Is the insured registered for VAT purposes? If YES, state the registration number and proportion recoverable: Section B Incident Details Date and time of incident: Where did the incident occur? Please explain fully and clearly, how the incident occurred:

2 Section B Incident Details continued When was the incident discovered? Who by? Was the building occupied at the time of the incident? If NO, when was the building last occupied? What steps have been taken to prevent a recurrence? Is any of the property claimed for owned by anyone other than the insured? If YES, please give full details of whom? Is the property claimed for also insured by any other policy? If YES, please confirm the full name and address of the other insurer, along with the relevant policy number: Has a claim been submitted to them? If YES, what was the outcome? In cases of Theft, Loss or Malicious Damage, the Police must be notified immediately. Have the Police been notified? If YES, when were they notified? What is the name and address of the Police station notified? What is the Police Incident / Crime Reference Number? In the case of Theft or Attempted Theft please complete these additional questions. How was entry gained to the building? How was exit made from the building? Were locks / security devices in force at the time of the theft? If YES please confirm what locks / security devices were in force: If NO please confirm why locks / security devices were not in operation: Is an alarm fitted to the building? If YES did this operate?

3 Section C Buildings Claim What is the estimated cost of repairs to the building? Please ensure that ALL estimates, quotations and invoices are submitted to us with this claim form. Are you a tenant? If YES, are you legally liable under a tenancy agreement for decorations or other repairs to the building? YES/NO* If YES, please send a copy of the tenancy agreement to us with this claim form. Section D Contents Claim If items have been damaged, have you explored the possibility of repair? If YES, what was the outcome? If items are damaged beyond repair, please provide confirmation from the repairer that this is the case. Please submit any repair or replacement estimates / quotations you have obtained or the original receipts if available. Description of item including make and model numbers where appropriate Original purchase price and purchase date Estimated cost of repair or replacement Section E Miscellaneous Claim Is there anything else that you wish to claim for, in addition to above? If YES, please give full details and submit documentary evidence where appropriate:

4 Section F Previous Claims Have you made any claims with this company or any other insurer in the last three years? If YES, please give details: Section G Payment Details If any payment is to be made, it will usually be in the name/s of the insured/s. If payment is requested to any other party, please confirm who: Section H Recovery Has anyone involved in the incident been identified? (For example a car driver involved in impact damage or a culprit involved in theft or malicious damage) If YES, please provide their names and addresses: It may be possible to make a recovery from those responsible, which would include your policy excess. Section I Additional Information Section J Declaration I / We declare that all the answers are true and correct to the best of my / our knowledge and belief. Signature: Please print your name in full: Date: Please state your position within the church, business or other organisation:

5 Regulated by and members of the General Insurance Standards Council and the Association of British Insurers. Authorised and regulated by the Financial Services Authority.

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