SOMERVILLE EXTENDED PROTECTION THEFT, LOSS or DAMAGE REPORT FORM
The issue of this form does not constitute an admission of liability on the part of Somerville. This form must be completed by the School or the Parent before the claim is considered.
School
Serial Number
Model Number
User Name
Manufacturer
Is there any insurance in force which could cover this loss in part or wholly? Yes No
Name of Insurer
Policy Number
Date of Incident
Type of Incident Accidental Damage Loss/Theft (Fill in Loss/Theft Section Only)
Where did damage occur?
Describe in full how damage occurred
Was anyone else involved? Yes No
Name of person
Relationship to You
Did anyone witness the incident? Yes No
Security Code
Did the Theft or Loss take place at Home School In Transit - Provide Details below From a Vehicle - Provide Details below Other - Provide Details below
Where did the Loss or Theft occur? Provide address or location details
Time of Loss or Theft
When was the equipment last seen by you?
At the time of Loss or Theft how long had the equipment been left unattended?
Were the Vehicle or Premises locked? Yes No
If "NO" please explain why.
How was access gained to the Vehicle or Premises?
If stolen from a vehicle where was the equipment?
Details of Loss or Theft
Station
Date
Time
Receiving Officers Name
Offence Report Number
I/We do solemnly and sincerely declare that I/we have complied with the conditions and warranties (if any) of the Somerville Extended Protection Agreement and in no manner deliberately caused the said loss or damage or sought unjustly to benefit thereby by any fraud or wilful misrepresentation and that the information shown on this form is true and that I/we have not concealed any information relating to this claim.
