Enquiry Form BELFOR Ireland loss-form-left Company Name First Name Surname Adress Line 1 Adress Line 2 Adress Line 3 Adress Line 4 Country Postcode Telephone Email loss-form-right Customer Category - Select -Homeowner Landlord/Managing Agent Business Public Body (e.g. school, hospital etc) Organisation Insurer Loss Adjuster Broker Other Incident Date Incident - Select -Fire Flood Explosion Escape of Water Oil Spill Accidental Damage Spill Impact Machinery Failure General Contamination What has been affected? - None -Structures & Fittings Machinery Electronics/IT Documents Stock/Material General Contents Emergency power Security (e.g. boarding up) Brief description of damage/any other relevant information Service required (if known)? - None -Technical Assessment Analysis Specialist Decontamination Drying Machinery Repair Re-instatement/Repair Emergency Power Security (e.g. boarding up) Image Video CAPTCHA Submit
