General Claims Form
Contact Person (if different)
Date of Happening
Street Address of Happening
New South Wales
Australian Capital Territory
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?
Was this incident reported to police?
Police report number
Name of police officer
Property damaged, lost, or stolen
Are you registered for GST?
If Yes, please provide your ABN
Preferred Payment Method
Direct Bank Deposit
Direct Bank Deposit - Account Name
Direct Bank Deposit - BSB
Direct Bank Deposit - Account Number
Cheque - Payable to
Have repairs been completed?
If yes, cost of repairs
If no, do you have
Please provide a copy of tax invoices/estimates or quotes
I/We hereby declare the foregoing particulars to be true and correct
For Office Use Only
Policy Due Date