RDA Upload RDA Claim Loading – Broker Section Broker/Agent * Policy #: * VAT #: Section Name * Surname * Occupation Phone # * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Date & Time of Loss Date and time of loss/damage * Time 121234567891011 : 0030 AMPM Date and time of discovery of loss/damage: * Time 121234567891011 : 0030 AMPM Place where loss/damage occurred * Were the premises occupied? * Yes No N/A By whom, and for what purpose? * When was it last occupied? * Section Describe fully how the loss or damage occurred stating how (if applicable) entry was gained to premises * If loss/damage caused by another party give name and address Section Have you previously suffered a loss/damage? * Yes No Please give the details: * If insured, provide name of insurer * Police Ref. no. and station and date reported * Submit If you are human, leave this field blank.
