Policy Details

Policy number:

Policy holder/Company name:

Email:

Phone no.:
Only numbers may be entered in this field.

Do you own the property?

Incident description

Date of incident:

Format: mm-dd-yyyy

Location of the incident:
Type of claim:
Please provide a brief description of the incident and the extent of damage:

Was the incident reported to the police?
To which police station was it reported to?

Is there any other insurance covering the same property?

Bank Details

Policy holder declaration

I declare that I have become eligible to make a claim under the terms of my policy and claim benefit accordingly. I certify that, to the best of my knowledge, the above information is true and correct.
I understand that if any information provided by me is found to be deliberately misleading or incorrect, this claim may be rejected and my Policy may be treated as invalid. In such circumstances, I also understand that I will have to repay any benefit that I have received to date and that legal action could be taken against me.
I authorise AXA to make any enquires and obtain any information they consider relevant from any doctor(s), employer(s), ex-employer(s) or elsewhere. I understand that I must provide evidence to AXA to prove my claim. I understand and give explicit consent that the sensitive health and other information I may provide about myself will be used, stored, transferred and/or disclosed by AXA, its agents and associated companies, other insurers, regulators, industry, and public bodies (including the police) and agencies to process this insurance and any other insurance, handle claims and prevent fraud. This may involve the transfer of such information to other countries.
AXA has taken steps to ensure that your information is held securely. You have the right to access your personal data held by AXA. If you believe that your personal data held by AXA is inaccurate you have the right to ask for this to be rectified.
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Appendix

In case of theft or multiple damaged items, please fill the form below.
Was the premise occupied when the property was damaged/stolen?
  No. Describe the property damaged/stolen Date & place of purchase Price paid/ Repair cost