Mandate Form

to help us manage your claim Please Fill Out all fields in the Form

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Insured name

Phone Number

Insured Address:

Insurer

Policy Number

Excess Amount

Date Of Loss

Type Of Loss

Claim Number

Insurers Name:

Insurers Phone Number:

Insurers Email

Overall Area

Buildings Sum Insured

Contents Sum Insured

General Description of the Damage

Form Of Authority

I/we herby authorise Gullion Loss Assessors Ltd. to deal with all aspects of the claim as referred to above, to meet with the loss adjusters and to negotiate settlement of my/our claim.

I/we give our consent that all correspondence in relation to the above claim from my/our insurers, or their agents, to be sent to Gullion Loss Assessors Ltd. without the necessity to be copied in any way of the said correspondence.

I/we undertake to pay Gullion Loss Assessors Ltd. a fee of 10% plus VAT of final claim payable on settlement of the claim. I/we declare that this authority is irrevocable

Signature Test

Witness Test

Dated

Witness Name

Gullion Ltd t/a Gullion Loss Assessors is regulated by the Central Bank of Ireland (C163734)
Gullion Ltd t/a Gullion Loss Assessors NI is regulated and authorised by the Financial Conduct Authority (FRN 935880)

Mandate Form

to help us manage your claim Please Fill Out all fields in the Form

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Paul Murchan

Niall Quinn