ࡱ> ^`]c BbjbjNN :N$i$i9 GG$V/p .......0|3.   .GG#/|"|"|" G8.|" .|"|"i-h.QK F-.&/0V/-44"!Z44 .44.@ |" ..|" V/ 44 Y :  The Issue of this form is not an admission of liability COMPUTER INSURANCE CLAIM FORM  Notes: Please complete Sections 1 and 2 and only the relevant part of section 3. Estimates should be attached where applicable. Tick boxes where appropriate.  Section 1 Insured: Full Name: University of TV _____________________________________________ Policy No: 100659289ENG Address: Sir William Lyons Road, Coventry ______________________________ Telephone No 1: 02467 524222  _________________________________________________ Telephone No 2: __________________________ Post Code: __CV4 7EZ______________________________________________  Occupation: ________________________________________________ VAT: Is the insured registered as a taxable person? NO If the insured is registered for V.A.T., is full remission of input tax obtained? YES NO If only partial remission of V.A.T. is obtained, state last annual adjusted percentage of tax recoverable ___________ % The Event: Date: ______________________ Time: ___________________________ Place: __________________________________________ When and by whom discovered: _____________________________________________________________________________________ State fully what happened: ______________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Name and address of person causing damage: __________________________________________________________________________  _______________________________________________________________________________________________________________ Police Notified: YES NO  If YES give the Date: _____________________ Station: ____________________________ Crime ref no: ______________________ Section 2: Goods / Property lost or damaged:  Are you the Sole owner: YES NO If NO who is?: ____________________________________________________________ Name and Address of all other interested parties: _______________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Are you responsible by an agreement for the goods/ property? YES NO Were the premises occupied at the time of occurrence? YES NO If NO State date and time last occupied: Date: _________________________ Time: __________________________ State total value of insured goods/ property: _________________________ ________________ ____________________________ Are there any other insurances on the goods/ property? YES NO If YES give details: _____________________________________________________________________________________________ Have you ever suffered a loss of this nature before? YES NO If YES give details: ______________________________________________________________________________________________ Section 3: Details of Claim Contents and/or Articles Specifically Insured (Mark an X in the last column if articles are on hire, loan, hire purchase, or belong to a customer) Description of articles, lost, damaged or destroyed and how damaged/lostDate purchased or acquiredCost of repairs or replacement. 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