Claim Form

Please read the following, and tick the checkbox to the left if you accept the declaration.

I declare that all the information I have provided relating to this claim represents a true and accurate statement of the circumstances and that I have not omitted any details.

I authorise the claims service to divulge to their agents or other third parties such information as may be necessary to assist in the processing of my claim.

In respect of claims relating to medial circumstances, I authorise my Medical Practitioner or other relevant person/body to provide any details which may be requested by the claims service or persons acting on their behalf.

I confirm that where my claim is made on behalf of others, I have authority to act on their behalf and accept responsibility for the disbursement of any monies due. Where the claim involves a potential refund e.g. from other Insurers or a third party, I authorise them to refund to the claim service on my behalf.

I understand that falsification of the information provided will result in the declinature of my claim and possible legal action against me.