Loss Instruction Sheet

Please enter the details requested and click the submit button at the bottom of the screen. Mandatory items have a bold title.

Your Details

Company/Broker Name:

Branch:

Official:

E-mail address:

Telephone number:

Policy Details

Policy Number:

Name of Insured:

Address of Insured:

Telephone Number of Insured:

Loss Details

Claim Reference:

Loss Type:

Situation of Damage:

Time, day and date of loss :

Excesses:

Estimate:

Deal on delegated authority?

Yes
No

Any Special Instructions:

Ellis May Chartered Loss Adjusters UK Head Office Uxbridge Middlesex UK t 01895 520101 f 01895 520102 claims@ellismay.co.uk