Engineering (including Computers) Claims Notification Form

You will be contacted by a claims handler in due course, who will advise you of the claims reference number and any further documentation that is required in support of your claim.

Please note that fields marked with asterisk (*) are mandatory.

Insured

Title*

Forename *

Surname *

Policy Number (prefix)

Policy Number

Address 1 *

Address 2

Address 3

City*

County*

Postcode, including spaces *

Email*

Are you registered under the VAT regulations?

What percentage can you recover?

Details of equipment involved in the occurrence

Full description. Include all known details e.g. Make, model, serial no*

Present Market Value

New Replacement Value

Is item owned by insured

Give details of owner and if hired in,where hired and details of hire contract if applicable

Was item hired out by the insured?

State to whom

Is the insured aware of any other insurances (whether or not in the insured's name) covering the loss or damage or liability?

Give details

Details of occurrence

Date of Incident *

Day Month Year

Time of Incident(hour)

Time of Incident(minute)

Place*

Describe how loss or damage occurred and give details of any Third Party responsible*

Who discovered the loss, damage or corruption? *

Details of loss or damage

Give particulars of loss or damage claimed*

Witnesses

Name and Address of witnesses

Repairs

Where damage has been sustained, provide an estimate for repair

Inspection

Where can the damaged property be inspected?

Contact Name

Contact Telephone Number

Theft

Name and address of police station involved

Date of notification

Day Month Year

Crime/User Reference Number

Has a thorough search been made for the missing property?

Is there any evidence of forcible or violent entry or exit?

Please provide details

Loss in Transit

Is this claim in respect of Loss in Transit?

Name and address of carriers and mode of conveyance

Indicate whether consigned at the Carriers or Owners risk

How was the property packed?

If damage occurred during loading or unloading, by whom was the operation carried out?

Computer Specific Questions

Is this claim in respect of computer equipment?

Security

Is the alarm installer and maintainer approved by the National Security Inspectorate(NSI) or the Security Systems and Alarms Inspection Board (SSAIB)?

If not shown on certificate advise level of certification held by the installer/maintainer(e.g.NIS NACOSS Gold, or NSI System Silver or SSAIB _UKAS or UKAS plus ISO 9000 accreditation)

Does your Intruder Alarm System signal activate an Alarm Receiving Centre?

What means of signalling is employed? (E.g. BT RedCARE, BT RedCARE GSM, Dualcom or Dualcom Plus)

Does your Intruder Alarm System comply with all the requirements of the Association of Chief Police Offices(ACPO) Intruder Alarm policy and where required provides confirmed alarms using confirmation technology?

Please advise why

When was the Intruder Alarm system last maintained?

Was the alarm set in its entirety at the time of theft?

Are the premises protected out of hours by: a. Static security guard(s) no patrols undertaken?

Please provide details of the guards employer and tasks and responsibilities

Are all external doors and any internal doors giving access to other parts of the premises not in your sole possession:

a. fitted and secured out of business hours by a mortice deadlock and box striking plate conforming to BS3621?
b. in case of locks having a cylinder mechanism fitted and secured out of business hours with a cylinder guard?
c. in case of hollow section frames (aluminium or upvc), fitted and secured out of business hours with box reinforced armoured striking plates?

Are key operated locks fitted and secured to all accessible opening windows out of business hours?

Are lock down plates or enclosures fitted to your equipment

Is the property marked with any other security devices to aid identification?

Please provide details

What steps have you taken to prevent a recurrence?

Data Media

Please provide full details giving total time to input and hourly rate

When was the media last backed up?

Day Month Year

Was the backup stored off site?

Dongles

Were these stored away from the computer at the time of theft?

Additional Expenses

Please provide full details

Amount Claimed

Terms & Conditions

Please read and confirm acceptance of Allianz Terms & Conditions*

I accept Allianz terms and conditions

Engineering (including Computers) Claims Notification Form

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