Loss Assessors Form - Gullion Ltd

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Date

Insured Name

Phone Number

Current Insurer

Policy Start Date

Policy End Date

Previous Insurer

Risk Address:

Type

Owner Occupied Rented

Duration at Property (months)

Do You Have a Mortgage

Person 1 at Property

Person 1 Occupation

Person 1 Date of Birth

Person 1 Criminal Convictions / CCJ'C / Bankruptcies

Person 2 at Property

Person 2 Occupation

Person 2 Date of Birth

Person 2 Criminal Convictions / CCJ'C / Bankruptcies

Person 3 at Property

Person 3 Occupation

Person 3 Date of Birth

Person 3 Criminal Convictions / CCJ'C / Bankruptcies

VAT Registration Status

Claims in Last 5 Years and Details of Same

Circumstances of Claim & Actions Taken

Reports Required

Gross Internal Floor Area / Domestic Outbuildings