Notification of a Claim

Upon your completion of this Claim Notification sheet, our Claim team will notify the insurers of your claim straight away. Please note however, you may also be asked by the insurers at a later date to complete a full claim form.

Your Personal Details
	Title
*	Forename	*	Surname
*	E-mail		Mobile
*	Telephone		Fax

Your Address
*	Company Name
*	Postcode, eg CF83 2WJ	*	Building Number/Name	Find

*	Address
			Town
			County

Your Claim Details
*	Type Of Claim			Date of Accident, eg, dd/mm/yyyy
*	Description
*	Cost		*	Location
*	Insurance Company
*	Policy Number		*	Policy Start Date, eg dd/mm/yyyy
*	Hire Equipment if any?	NoYes	*	Reported to Police?	NoYes
*	Are you at fault?	NoYes
	Additional Comments

COBRA Electronic Solutions is delivered and managed by Moorhouse Xbroker, a trading style of Moorhouse Group Ltd of Barclay House, Pontygwindy Road, Caerphilly, CF83 2WJ, Wales and is registered in Wales number 3825233.
Moorhouse Group Ltd is authorised and regulated by the Financial Services Authority. FSA membership number 308035.
COBRA Electronic Solutions (XBroker) is a trading style of COBRA Underwriting Agencies Limited.