Make a Civil Claim - The Pharmacy Insurance Agency

Make a Civil Claim

Details of Insured

Policy Number

Full Name

Address

District

Town

Post Code

Email Address

Phone Number

Details of Claimant

Full Name

Address

District

Town

Post Code

Details of Claim or Circumstances

Date of Incident

Description of incident

Description of injuries

Date made aware

How were you made aware

Details of Response

Delarations

The information and answers given above are true, correct and complete in every detail.

I understand the claim may be refused if information is not true or is withheld.

The Pharmacy Insurance Agency Limited is registered in England and Wales under company number 2591975
It is authorised and regulated by the Financial Conduct Authority (Register No 307063)