Policyholder Name

Reference Number / Policy Number:

Solicitors/Conveyancing Company:

Agent Company:

Address of the Property Subject to this claim:

Did the Policyholder make an offer on the Property that was accepted (please confirm the value of the offer)?

Please confirm the nature of the event that caused the transaction to fail:

Date of the event that caused the transaction to fail:

Are you aware of any previous survey being undertaken on the property in the 90 days prior to the inception of the Policy:

If your claim has arisen due to redundancy, please confirm:

Is the Policyholder self-employed?

Is the Policyholder a company Director or Partner in the entity that gave notice of redundancy?

Was the redundancy voluntary?

Please attach copy invoices / receipts for the costs that are being claimed.

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