Machinery Breakdown Claims

Claim Form - Machinery Breakdown

DD slash MM slash YYYY
Address Where Incident Occurred(Required)
Do you consider any other party responsible for the loss?
Are you the sole owner of the property lost or damaged?
Is the motor under a manufacturers warranty?
Details of Damaged Items(Required)
Item Damaged
Purchase Date
Replacement Value
DD slash MM slash YYYY
Drop files here or
Accepted file types: png, jpg, pdf, doc, docx, Max. file size: 16 MB.