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
Other
Signature
Signature
Submit
Should be Empty: