Nicholas Anthony & Associates

Please Tell Us Some Details

As independent Loss Adjusters, our aim is to assist and make it easier for people to advise of their claims circumstances.

So for people on the move, please complete the section below for the loss of luggage and personal items. This e-claim form can actually be lodged from anywhere and anytime.

Simply fill in the text boxes below and submit the form.

For more information on our e-claim form please click here for FAQ.

First name
Surname name
Date of birth
Residential address
City
State
Postcode/zip
Country
Home phone
Mobile phone
E-mail address

Incident

Please complete a separate form for other incidents

Date of loss
Approx time
Location
City/town
Country
Other
Date discovered
Approx time
Loss Reported	Yes No
If not why?
Police report	Yes No
Please explain (in detail) how the loss or incident occurred

Please list property lost or stolen (advising of any proof of purchase/ownership)

Please list medical claim details (advising of any receipts)

Passport/Ticketing Details

Passport no.
Issued in
Other
Airline/carrier
If other
Departure date
Arrival date
Number of bags on departure
Bags on arrival
All your bags?	Yes No
If not, details
Still abroad?	Yes No
If yes expected date of return

Please tell us

(you're almost finished)

First time claiming travel insurance? Yes No
Please list other current insurance policies:
Home & contents	Yes No
If yes name
Motor vehicle	Yes No
If yes name
Business	Yes No
If yes name
Other insurance

Submit

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Nicholas Anthony & Associates

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Incident

Passport/Ticketing Details

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E-Claims

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