New Instructions Form | Rapidrelocate

Insurance Company Name:*

Financial Owner:*

Policyholder Name:*

Branch Location:*

Claims Handler/Loss Adjuster Name:*

PH Address (inc postcode):*

Insurer Ref:*

Policyholder Work No:

Loss Adjuster's Ref:

Policyholder Home No:

Phone Number:

Policyholder Mobile No:*

Mobile Number:*

Policyholder Email:*

Email Address:*

Secondary Loss Adjuster Contact Details:

Type of Loss:*

Date of Loss:

Type of Current Property:

Location of Customer's Work:

Number of Bedrooms:

Number of Adults in Household:*

Pets? Please Provide Details:*

Number of Children (inc sex/ages) in Household:*

Location of School(s):

Any Vulnerable Customer?*

Smokers:

Additional Comments/Special Requirements:

If kitchen is main area of damage Is part of the property habitable/safe?

If bathroom main area of damage is part of the property habitable/safe?

Is kitchen capsule or pod an option?

Is bathroom pod an option?

If not immediately an option might it be in a few weeks?

Have white goods been damaged?

Is there an appropriate driveway for a bathroom or kitchen pod?

Is customer able to clear space for capsule if Is customer able to clear space for capsule if appropriate?

Immediate requirements (e.g. hotel?):*

Date from and to:*

Estimated length of total AA requirement*

Thank you for submitting your details. We will be in touch as soon as possible.