ࡱ> ] sbjbjgg Q &b &b* v"X X $$$$HHHP<dHzzzwl8ώюююююю$88]$vlwzVRF8z$ώώW wۇFoh0wp!8pp$<'t'''Y'''p'''''''''X B :  eClaim form Public liability  InsuredPlease complete the form as fully as possibleZurich Claim Number FORMTEXT      Name FORMTEXT HERIOT-WATT UNIVERSITYPolicy Number FORMTEXT NHE  FORMTEXT 15CA010013  FORMTEXT    Details of claims and claimantIncident circumstances and details of loss / injury / damage suffered FORMTEXT      Title FORMTEXT      Initial FORMTEXT     Surname FORMTEXT      Address  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT      Postcode FORMTEXT      Phone number FORMTEXT      Department  FORMTEXT      FORMTEXT      Occupation FORMTEXT      FORMTEXT      Employment status FORMTEXT      FORMTEXT        Incident date and timeDate and time of incidentDate FORMTEXT      Time FORMTEXT      For gradually occurring incidents such as damp, please state period of the alleged exposureFrom  FORMTEXT       to  FORMTEXT       Location of incidentIs the land / property within your ownership? FORMDROPDOWN If not, please state your involvement / responsibilities FORMTEXT      Address FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT      Postcode FORMTEXT       Claimant representative (if applicable)Name FORMTEXT      Reference FORMTEXT      Address  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT      Postcode FORMTEXT      Phone number FORMTEXT       Contractors details (if applicable)Name FORMTEXT      Reference FORMTEXT      Address FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT      Postcode FORMTEXT      Phone number FORMTEXT      Claim Number  FORMTEXT        Claim Number FORMTEXT      Documentation - Please forward all relevant documentation.Tenancy agreement FORMD@BDJZ     ( ~kX~I?hhWj5CJjhhWj5CJU$jh5;CJUmHnHu%jhhWj5;CJUhhWj5;CJjhhWj5;CJUhhWjCJhhWj5CJ$jh-nhWjCJUmHnHuh-nhWjCJh-nhWjOJQJjh-nhWjOJQJUh-nhWjCJmHnHuh-nhWjCJmHnHu@BHJZ $If $$Ifa$ & F$Ifdh@&    \ x gaaaa$Ifkd$$Ifl4d\!*904 lalf4( * , X Z \ x z ȿoү\Iȿ$jh5;CJUmHnHu%jhhWj5;CJU%jshhWj5;CJUh 425;CJmHnHu%j hhWj5;CJUhhWj5;CJjhhWj5;CJUhhWjCJhhWj5CJh 425CJmHnHujhhWj5CJU"jwhhWj5CJU 2 ge[ & F$IfkdY$$Ifl4e\}*04 lalf4 2      . 0 D F H P R T d f z | ~ ݰӞݰӌݰzݰhݰ"jhhWj5CJU"j(hhWj5CJU"jhhWj5CJU"jhhWj5CJU!jh5CJUmHnHu"jhhWj5CJUhhWj5CJjhhWj5CJUhhWjCJhhWj5CJ(2 4 +qkdI$$Ifl4^0 * 04 lalf4$If[kd$$Ifl**04 lal  . 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FORMTEXT      FORMTEXT       Additional information and declarationAny additional information which may be relevant FORMTEXT      By submitting this completed form I declare that all answers are true and correctDate FORMTEXT      Contact name FORMTEXT      Job Title FORMTEXT      Address FORMTEXT      Postcode FORMTEXT      E-mail address FORMTEXT      Phone number FORMTEXT      Your reference FORMTEXT      Claim Number  FORMTEXT           Zurich Municipal is a trading name of Zurich Insurance company. A limited company incorporated in Switzerland. Registered in the canton of Zurich. No. CH-020.3.929.583-0 UK branch registered in England. No. BR105. UK Registered office: Zurich House, Stanhope Road, Portsmouth, Hampshire PO1 1DU. Authorised and regulated by the Financial Services Authority.  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