Assign A Claim * indicates required field Your Name:* Contact Number:* Email: Instructing Party: Reference No: Insured? Yes No Insurance Company: Location of Incident: Date Incident Occured: Description of Incident: Estimated Loss (£) Additional Information: Use this section if you want to sent in any supporting documents Supporting Attachment 1? Acceptable file types: doc,docx,pdf,txt,gif,jpg,jpeg,png.Maximum file size: 1mb. Supporting Attachment 2? Supporting Attachment 3? Enter Code Below CAPTCHA Code:* *Please note all data submitted through this form will be kept securely and will only be viewed by authorized personnel within our organization.