Claim Submission Form

"*" indicates required fields

Please fill in this form to the best of your ability and make sure to complete all relevant fields. If you are unsure or don’t have enough information, please skip or type in N/A.

Permitted files JPG, PDF, PNG can not be larger then 10MBs per file

A) Details of Membership

Member Name

Contact Person

Telephone

Fax

Email*

Member Number

Is the Business VAT registered? If yes please add number

B) Details of Event

Date of Event

Time of Event

Where did the Event occur?

Is any Third Party to blame for the loss or damage? If so, give name and address.

Brief Description of loss or damage (including cause) (required)

C) Claims for loss by BURGLARY, THEFT or MALICIOUS DAMAGE

Method of Entry

The extent to which the premises/items were protected from loss or damage at the time of the occurrence, eg.alarm, cctc, locks, or any other security

How many shelves do you have in your cigarette gantry?

What is the size of your cigarette gantry (HxWxD)?

Have Police been notified? If so, give station, date and crime reference if known. (required)

D) Cost of Damages

Please complete for all items being claimed for, attaching additional sheets as necessary

Loss of Property

Description of property for which loss is claimed

Serial No's of items

Current Replacement Cost

Value of Salvage (if any)

Date of purchase or acquisition

Amount of Loss or damage claimed

Description of property for which loss is claimed

Serial No's of items

Current Replacement Cost

Value of Salvage (if any)

Date of purchase or acquisition

Amount of Loss or damage claimed

Description of property for which loss is claimed

Serial No's of items

Current Replacement Cost

Value of Salvage (if any)

Date of purchase or acquisition

Amount of Loss or damage claimed

Description of property for which loss is claimed

Serial No's of items

Current Replacement Cost

Value of Salvage (if any)

Date of purchase or acquisition

Amount of Loss or damage claimed

Description of property for which loss is claimed

Serial No's of items

Current Replacement Cost

Value of Salvage (if any)

Date of purchase or acquisition

Amount of Loss or damage claimed

Damage of Property

Description of Property and scope of damage

Name of repairer (invoice / quotation to be attached)

Name of repairer (Invoice)

Max. file size: 25 MB.

Cost of repairs

Description of Property and scope of damage

Name of repairer (invoice / quotation to be attached)

Name of repairer (Invoice)

Max. file size: 25 MB.

Cost of repairs

Description of Property and scope of damage

Name of repairer (invoice / quotation to be attached)

Name of repairer (Invoice)

Max. file size: 25 MB.

Cost of repairs

Description of Property and scope of damage

Name of repairer (invoice / quotation to be attached)

Name of repairer (Invoice)

Max. file size: 25 MB.

Cost of repairs

Description of Property and scope of damage

Name of repairer (invoice / quotation to be attached)

Name of repairer (Invoice)

Max. file size: 25 MB.

Cost of repairs

Please Note:

(1) Tax Invoices for repairs or replacement must be submitted.

(2) Where an item of equipment must be replaced, and you propose to replace that item with:

:- The same brand of equipment, but a different model; or
:- The same brand of equipment, but a different model; or

You must indicate whether the replacement equipment is the equivalent of, or better or more extensive than, the equipment it is replacing.

Additional Information

Additional File - 1

Max. file size: 25 MB.

Additional File - 2

Max. file size: 25 MB.

Additional File - 3

Max. file size: 25 MB.

Additional File - 4

Max. file size: 25 MB.

E) Declaration

Full Name*

Date*

Permitted files JPG, PDF, PNG can not be larger then 10MBs per file

The Retail Mutual is a trading name of the NFRN Mutual Limited, a company registered in England and Wales, number 3810528, registered office Barrington House, Heyes Lane, Alderley Edge, Cheshire, SK9 7LA. The NFRN Mutual Limited is authorised and regulated by the Financial Conduct Authority, FRN: 312391. The NFRN Mutual Limited is managed by InShare Insurance Services Limited, a company registered in England and Wales, number 12598390, registered office Barrington House, Heyes Lane, Alderley Edge, Cheshire, SK9 7LA. InShare Insurance Services Limited is authorised by the Financial Conduct Authority, FRN: 965006. You can check this on the Financial Services Register by visiting the FCA's website

Opening times

Customer Service and General Enquiries

Customer Service - 0333 2121 006
9:00am to 5:00pm, Monday - Friday
Closed Weekends and Bank Holidays

Claims Team

Claims - 0333 2121 008
9.00am to 5.30pm, Monday - Thursday
9.00am to 5.00pm, Friday
Out of hours - 01424 850 333