Home Insurance Claim Form

Policy Holder Details

Policy Number

Name*

First Last

ID Number*

Email Address*

Enter Email Confirm Email

Contact Phone Number*

Contact Mobile Number

Address of Property Insured*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Postal Address

Same as previous

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Part 1 - Details of Loss

Date of Accident*

Time of Accident

: HH

MM

Police/Warden's Report Number (if applicable)

Where the premises occupied?*

Yes
No

Details of Inoccupancy

Description of claim*

State exactly how the loss or damage occured

Is the property owned by you?*

Yes
No

To whom does the property belong?

Have you previously suffered loss or damage of similar cause?*

Yes
No

Provide details of previous loss/damage

Was there at the time of the occurrence any other existing insurance?*

Yes
No

Provide details of other insurance

Part 2 - Burglary/Theft Details (if applicable)

Date of Theft

Date when the theft was discovered

Time of Theft

Time when the theft was discovered

: HH

MM

Discovered by

By whom the theft was discovered

Where the premises occupied at the time of theft?

Yes
No

When were they last occupied?

How was entry gained?

If burglary/theft was from building

Date of Report

Date when the incident was reported to a police station

Time of Report

Time when the incident was reported to a police station

: HH

MM

Address of Report

Address if the police station the incident was reported to

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Part 3 - Liability to Third Parties

Third Parties

Name of Third Party	Damages sustained by Third Party
		Edit Delete
There are no Third Parties.

Maximum number of third parties reached.

Part 4 - Particulars of Claim

Please attach the original repair/replacement estimates

Items Claimed

Item being claimed	Original Cost Price
		Edit Delete
There are no Items.

Maximum number of items reached.

Injured Persons

Name	Nature of Injury
		Edit Delete
There are no Persons.

Maximum number of persons reached.

Photos of Damages & Documents

Drop files here or

Terms Accept*

I have read and accept MIB's Client Terms of Business & Privacy Policy.*

Some or all of the information which you supply to Mediterranean Insurance Brokers (Malta) Ltd. in connection with this claim, will be held by the Company and may be passed to other insurance companies and insurance associations for underwriting and claims handling purposes and for the fight against fraud.

I/We declare that the above statements are true and correct to the best of my/our knowledge and belief.
I/We have not withheld from the Insurers any information within my/our knowledge connected with this claim.
I/We agree to provide the Insurers with any further information or documentation as may be reasonably required.
I/We understand that the Company is not committed to be liable by the completion of this Claim Form.

I understand that by completing this form the data will be processed by MIB in line with GDPR and hereby consent that this data (including if needed sensitive data as defined in article 9 of GDPR) are used for the purposes of providing your insurance services.

I also understand that it is my responsibility to secure and hold the necessary consent from any employees, beneficiaries or other third parties direct or indirectly involved in the insurance proposal/arrangements and whose data will be processed by MIB and the providers of insurance and ancillary services.

Home Insurance Claim Form

Policy Holder Details

Part 1 - Details of Loss

Part 2 - Burglary/Theft Details (if applicable)

Part 3 - Liability to Third Parties

Part 4 - Particulars of Claim

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