Assessor Customer Name(Required) Claim Reference Number(Required) Insurer(Required) Claims Handler Claim Handler Email Central Forwarding Email(Required) Park Name if Applicable Make and Model of Home Age of Home Date of LossDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Risk Address(Required) Address Line 1 Address Line 2 Town/City Post Code Landline NumberMobile NumberOther Phone NumberCustomer Email Policy Excess(Required)Work Required(Required)Special InstructionsQuote Price(Required)Mileage if applicable(Required)Please type 0 if no mileage
