Page 155 - claims information pack ebook_e
P. 155
Example Claim Form Claim Number(s) (for internal use only)
PART 1
Claimant's details
Claimant’s Details
1 Title
2 First/Given name(s)
3 Surname/Family name(s)
4 Age
5 Date of Birth (day/month/year)
6 Social Security/National Reference/
Identification Number (as applicable)
7 Name of Business/Partnership/Association/
Cooperative/Company/Company number/
Government Department or Agency/
10 Other (as applicable)
8 Are you the sole owner of the business or the sole
appointed representative of the government agency etc., Enter X as applicable Yes No
which is the subject of the claim?
If NO, please describe the relationship of the claimant
to the business
9 Contact details (please specify the address at which you
wish to be contacted by entering X in relevant checkbox)
(a) Claimant’s address Address:
Claimant’s telephone number, fax number Tel:
and email address
Fax:
E-mail:
(b) Business address (if different to above) Address:
Business telephone number, fax number Tel:
and email address
Fax:
E-mail:
