General Claims Form

Client Information

Insured's Name
E-mail
Phone Number
Mobile
Contact Person (if different)
E-mail
Phone Number
Mobile

Claim Information

Date of Happening
Time
Street Address of Happening
Suburb
Post Code
State
Name Party Responsible for Damage (if known)
How did loss or damage or accident occur?
If water damage, what was the source of the water and how did it enter the building?
Extent of loss or damage and description of property affected
If burglars or malicious persons involved, describe how building was entered and state damage caused
Who discovered loss?
Date it was discovered?
How was the loss discovered?

Police Details

Was this incident reported to police?
Police report number
Date reported
Where reported?
Name of police officer

Damage Details

Property damaged, lost, or stolen
Insert photo
Insert photo
Insert photo

GST Status

Are you registered for GST? *
If Yes, please provide your ABN

Payment Details

Preferred Payment Method *
Direct Bank Deposit - Account Name
Direct Bank Deposit - BSB
Direct Bank Deposit - Account Number
Cheque - Payable to

Repairs

Have repairs been completed?
If yes, cost of repairs
If no, do you have
Please provide a copy of tax invoices/estimates or quotes

Declaration

I/We hereby declare the foregoing particulars to be true and correct

For Office Use Only

Policy Due Date
Policy Number
Insurer