Bright House Claim
Name*
First Name Last Name
Mobile No.
Email*
example@example.com
Date of Birth*
Day Month Year
Date
When did you take out items with BrightHouse (e.g. "2011 - 2013"?*
What items did you take out with BrightHouse (e.g. "a cooker and a TV")?*
Which BrightHouse branch locations did you take items out from (e.g. "Salford Shopping Centre")? *Your answer*
How many items in total did you take out with BrightHouse (approximately)?*
Please can you tell us your BrightHouse account numbers
When you took out items with BrightHouse, were you retired and receiving a pension? Please select 'yes' if this was true for any of the times you shopped at BrightHouse.*
YES NO
Were you receiving any state benefits when you took out items with BrightHouse? (You can tick multiple boxes here. Please select 'yes' if this was true for any of the times you shopped at BrightHouse.
Yes, I was receiving benefits related to sickness or disability Yes, I was receiving unemployment/jobseekers benefits Yes, I was receiving carer's allowance Yes, I was receiving housing benefit Yes, I was receiving other state benefits not listed above No, I was not receiving benefits
Signature
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Signature
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Bright House Claim