Claim Step 3 Step1 Step2 Step3 WIGGLE CLAIM FORMPlease complete this form for all types of claims. WITNESSES Witness name Witness contact number POLICE REPORT Police station Date and Time reported Date E.g., 12-07-2018 0:001:002:003:004:005:006:007:008:009:0010:0011:0012:0013:0014:0015:0016:0017:0018:0019:0020:0021:0022:0023:00 Police report number OTHER INSURANCE Do you have other insurance like home and Contents? Yes No If yes, please provide details Declaration x I hereby certify that the information given in the form is truthful, accurate and complete. No information likely to affect this claim has been withheld. I understand that this claim may be refused if information is untrue, inaccurate and concealed. I authorise Wiggle Cycle Insurance to give to, or obtain from other insurers or any insurance reference bureau, any information relevant to this claim or any other claim made by me on any insurance policy held by me.