Nil Claims Declaration

Insured Name(Required)

Policy Number(Required)

Email address(Required)

I/We, after having made full enquiries, declare that the information given at inception(Required)

has not materially altered, and that I/We are not aware of any new claim or circumstances which might give rise to a claim hereunder.

Date(Required)

Name(Required)

Signature of Insured(Required)

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