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Online Claim Form
Shaun Ryan
2015-06-02T14:37:30+00:00
If you are a human and are seeing this field, please leave it blank.
Fields marked with an
*
are required
Name of Insured
Contact Person
Contact Number (s)
Email address
Policy Number
Inception Date
Expiry Date
Interested Parties
Is The Property Being Claimed For Under A Financial Agreement?
Yes
No
Name of Financer
Contact No
GST
Are you registered for GST purposes?
Yes
No
ABN
Incident Description
Please Explain What Happened, How It Happened ANd Who Was Involved In The Incident.
Date of Loss
Time of Loss
Type of Loss
Address Where Loss Occurred
Postcode
Date premises last occupied
Name of last occupier
Schedule
Description of property
Year Purchased
Where Purchased
Replacement or repair cost
Amount Claimed
ITC % Entitlement
Police
Have The Police Been Notified? (All Burglary/ Theft? Malicious Damage claims must be reported)
Yes
No
Police Station
Reporting Officer
Police Report No
Date Reported
Security
Please Give Details Of Any Extra Precautions / Security Improvements Made Since The Loss
Please Give Details Of Other Actions Taken To Recover Or Reduce Your Loss
Third Parties
Do You Know Who Was Responsible For The Damage?
Yes
No
If Yes, Please Complete The Following
Name
Phone No
Address
Post Code
Other Details
Witnesses
Were There Any Witnesses To The Event?
Yes
No
If Yes, Please Complete The Following
Name
Phone No
Address
Postcode
Where Was The Witness?
Is There Any Other Insurance On The Property?
Yes
No
Name of insurer
Policy Details
History
Have You Had Any Insurance Or Renewal Insurance Declined Or Cancelled Or Special Conditions Imposed In The Last 5 Years?
Yes
No
Have You Ever Been Charged Or Convicted Of A Criminal Offence?
Yes
No
Have You Suffered A Loss Or Made A Claim On A Property Related Insurance Claim In The Last 5 Years?
Yes
No
If Yes To Any Of The Above, Give Details.
Please Upload Any Documentation Relevant To Your Enquiry
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