• Country * Anguilla Antigua Belize Bahamas British Virgin Islands Cayman Islands Fidelity Insurance (Cayman) Ltd. Grenada Guyana Montserrat St. Kitts St. Lucia St. Vincent Turks & Caicos U.S. Virgin Islands
• Policy Number

• Insured's First Name *
• Insured's Surname *

• Tel (Home)
• Mobile No: *

• Tel (Work):
• Other Contact Numbers:

• Email Address: *

• Postal Address *

• Loss Location (with directions) *

• Were the premises occupied at the time of the loss? * Yes No

• When were they last occupied?

• What were the premises being used for? *

• Are you the sole owner of the property? * Yes No

• Give particulars of other interest

• Are there any other insurances on the property? Yes No

• Please give full particulars

• Description of Loss: *

• If you wish to submit photos of your loss, please upload below.

• Photo #1

• Photo #2

• Photo #3

• By submitting this form, I do hereby declare that the above is a true and accurate statement with respect of the above loss.