Please answer all questions

For Completion By Removal Contractor

Name of Removal Contractor

Address

Name of Claimant

Telephone number

Present address of claimant

Collected from

on (date)

Stored at (if applicable)

Finally delivered to:

on (date)

Name of delivery agents

Date of discovery of loss

or damage

By whom discovered

Date reported to you

Full value of property

removed

£

Estimated value of all china, glassware and brittle articles included in the above full value figure

£

Are you satisfied that the damage complained of does not include pre-transit defects?

Yes

No

Please attach the following documents where available:

Signed copy of estimate and acceptance of quotation / trading conditions

Yes

No

Copy of trading conditions if not covered under remover’s block policy

Yes

No

Signed collection note

Yes

No

Signed delivery receipt

Yes

No

Signed inventory

Yes

No

Copy of invoice for removal

Yes

No

If registered with FSA, please quote authentication number:

Not Applicable

If payment is agreed would you prefer settlement to be sent direct to claimant?

Yes

No

If an excess applies to your policy, or a deductible is included in your trading conditions, please state the amount which is to be deducted from any payment to the claimant:

£

If this amount is less than your policy excess, do you refund the difference to the claimant?

Yes

No

Was any china, glass etc packed by customer?

Yes

No

Unpacked by customer?

Yes

No

Kindly provide Drivers or Foremans statement wherever possible.

I/we declare the above particulars and statement to the best of out knowledge to be true.

Signature  

Date