I declare that the above statements are true and correct to the best
of my/our knowledge and belief. I have not withheld from the insurer any information within my knowledge connected with this claim.
I agree to provide the insurers with any further information and documentation as may be reasonably required.
I understand that insurers do not admit liability by the issue of this form.
If you would prefer to complete your form on paper, please download the PDF file below.