Checkmate - Claim Form

Please complete all information requested below and then click on Submit to send us your claim form.
Fields marked in Bold and marked with a * are required and must be entered.

Your Contact Information

Title(Mr/Mrs etc) :

First Name:

Last Name:

Telephone:

Email:

Your address(if different from insured address):

Address Line 1:

Address Line 2:

Address Line 3:

Town:

County:

Postcode:

Insured Property Details

Insured address:

Address Line 1:

Town:

County:

Postcode:

Policy Number:

Policy Holder:

Date you moved in to the property(DD/MM/YYYY) :

Please confirm the amount of any retention held from the Developer(Retention is any money held back by you against the purchase of the property) :

Please provide details of any alterations / modifications to the property after the Effective Date on the Certificate:

Original Vendor(Developer/Contractor)

Vendor:

Claim Details

Please supply a brief description of the problem you have identified.

How long has the damage been evident?

Has the problem described above been notified to the Developer and if so, how and when?

What action, if any, has been taken by the Developer or by you to remedy the problem?

Disclosure and Data Protection

Disclosure

As you are the policyholder in your personal capacity(this means as a natural person i.e.not a limited company, or as part of your profession), we believe you are a consumer for the purposes of the Consumer Insurance(Disclosure & Representations) Act 2012. As a consumer, you no longer have a duty of disclosure, but you do have a duty to take reasonable care(that is, the care a reasonable consumer would take) not to make misrepresentations to the insurer in answering any questions.This means that the insurer will not pay out on any claims and may in fact demand repayment of any claims already paid if you make a misrepresentation when answering questions.If the insurer obtains evidence that you were careless or reckless in answering questions they ask you, the insurer may give you notice that they are cancelling the policy.In the event of a claim your insurer may deal with the matter on the basis of the terms that would have applied had there been no misrepresentation, or may proportionately reduce any indemnity payments to account for the misrepresentation.

Data Protection

Information about you(including, but not limited to, the information provided on this form) ("Data") will be held by us and will be processed by us in accordance with the Data Protection Act 1998 in order to provide you with the services you require.Your Data will be held securely, and unless required to do so by law or as stated below, we will not share such Data with any third parties.We will share your Data with the original vendor(developer/contractor) of the insured property in order to progress the claim detailed by you in this form.By signing this form you consent to us disclosing the Data as set out above.

Print Name:

Date: