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Homeowner’s Claim Form

Step 1 of 7 - Claimant Disclaimer

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Claimant's Declaration*
I declare that to the best of my knowledge and belief, the information to be provided by me is true and correct, and that I will not withhold any information connected with this claim being filed by me.

I understand that Gulf Insurance Limited requires the information in this form as part of its review of the claim being filed by me.

I am aware that failure by me to provide information that is true and correct, or which I believe may not be true and correct, or withholding information relevant to this claim may result in Gulf Insurance Limited denying or voiding my claim, and/or pursuing criminal actions and/or civil proceedings against me in accordance with the relevant laws of the land.

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INSURED
Are you an individual or a company?*
Company Name*
Salutation
First Name*
Last Name*
Policy No.
Contact No.
Email*
Address 1
Address 2
Town/City*
Country*
Is the Property Mortgaged?*
- Yes
- No
Details of Mortgage*
Are you VAT Registered?*
- Yes
- No
Enter your VAT details*

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CAUSE OF EVENT
Date of Loss*
Date Format: MM slash DD slash YYYY
Time of Loss*
What do you believe was the cause of the event?*
Please give a brief description of what happened*
Were premises occupied at the time of loss?*
Please state how long the premises were unoccupied for
Third Party's First Name
Third Party's Surname
Third Party's Contact No.
Policy No.
Insurance Provider
Insurance Provider
Insurance Provider
Insurance Provider
Insurance Provider
Insurance Provider
Insurance Provider
Insurance Provider
Insurance Provider
Coverage Type
Please State badge number of Police Officer.*
(If unknown, please state unknown)
Please state name of Police Station*
Please state name of Police Officer
(If unknown, please state unknown)
First Last

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DETAILS OF PROPERTIES DAMAGED
Is it a total loss claim?*
Were properties damaged/destroyed?*
Submission of a detailed cost estimate is required with this form
Were properties damaged/destroyed?*
Press Control/CMD on your keyboard and do multiple selection
Property Damaged
Please give an Approximate Date*
Please state an Approximate Amount*
Air Conditioning Units*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Price*
Bath Tub*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Price*
Bird Bath*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Price*
Burglar Proof*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Ceilings*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Counters*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Cupboards*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Doors*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Driveways*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Electrical*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Fence*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Fixed Carpets*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Flooring*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Garage*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Gate*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Gazebo*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Heaters*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Jacuzzi*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Lighting Fixtures*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
How many other property damage was there?
Please enter a number from 1 to 12.
Other*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Other*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Other*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Other*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Other*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Other*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Other*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Other*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Other*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Other*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Other*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Other*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Pathways*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Patios*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Pumps*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Railings*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Roof*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Satellite Dish*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Security Alarm System*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Staircase*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Swimming Pool*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Terraces*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Tiles*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Tool Shed*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Walls*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Water Tanks*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Windows*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*
Yard*
Date of Purchase*
Date Format: DD slash MM slash YYYY
Amount Claimed*

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DETAILS OF CONTENTS DAMAGED
Were contents damaged or destroyed?*
- Yes
- No
Contents Damaged or Destroyed
Press Control/CMD on your keyboard and do multiple selection
*No one item can exceed 5% of the Sum Insured (Value) of its Category (General Contents, Jewellery, Electronics).
Bedroom Suite*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Books*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Cabinets/Shelves*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
China/ Ornaments*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Clocks/Antiques*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Clothing/Footwear*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Desks*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Crockery/Glassware*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Dining table/ Tables*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Dishwasher*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Food mixer/ Processor*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Lawnmower*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Light fittings/ Lamps*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Microwave*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Paintings/ Artwork*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Patio Set*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Rug/ Curtains/ Drapes*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Silverware*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Sofa Set*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Standing Fans*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Stove*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Toys*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Washing machine/ Dryer*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Bracelets*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Earrings*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Necklaces*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Watches*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Rings*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Fridge/ Freezer*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Stereo Systems*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Home Theaters*
Approximate Date of Purchase*
Date Format: DD slash MM slash YYYY
Approximate Value*
Other
Content Title*
Date of Purchase*
Date Format: DD slash MM slash YYYY

Sum Insured*

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INTEREST IN PROPERTY
Is the insured the sole owner of the property?*
Please give details of other owner
Salutation
First Name*
Last Name*
Address 1
Address 2
Town/City*
Country*
At the time of the occurrence were there any other insurances on the property?*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Other*

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Signature*
- Type-in Signature
- Digital Signature
Type Signature
Signature*
Signature*
Declaration*
By signing or printing my name, I agree that this signature will be an electronic representation of my signature for all purposes when I use them on this document, just the same as a wet ink signature on paper.
Date*
Date Format: DD slash MM slash YYYY
Would you like this form to be e-mailed to an additional person?*
- Yes
- No
Email*

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Air Conditioning Units
Bath Tub
Bird Bath
Burglar Proof
Ceilings
Counters
Cupboards
Doors
Driveways
Electrical
Fence
Fixed Carpets
Flooring
Garage
Gate
Gazebo
Heaters
Jacuzzi
Lighting Fixtures
Pathways
Patios
Pumps
Railings
Roof
Satellite Dish
Security Alarm System
Staircase
Swimming Pool
Terraces
Tiles
Tool Shed
Walls
Water tanks
Windows
Yard
Other

--- GENERAL CONTENTS
Bedroom Suite
Books
Cabinets/Shelves
China/ Ornaments
Clocks/Antiques
Clothing/Footwear
Crockery/Glassware
Desks
Dining table/ Tables
Dishwasher
Food mixer/ Processor
Lawnmower
Light fittings/ Lamps
Microwave
Paintings/ Artwork
Patio Set
Rug/ Curtains/ Drapes
Silverware
Sofa Set
Standing Fans
Stove
Toys
Washing machine/ Dryer
Underground supply pipes and cables
Other
--- JEWELLERY
Bracelets
Earrings
Necklaces
Watches
Rings
Other
--- ELECTRONICS
Fridge/ Freezer
Stereo Systems
Television Sets/ Home Theaters
Other

Homeowner’s Claim Form

Step 1 of 7 - Claimant Disclaimer

INSURED

CAUSE OF EVENT

DETAILS OF PROPERTIES DAMAGED

DETAILS OF CONTENTS DAMAGED

INTEREST IN PROPERTY