General Insurance Claim Policy NumberDue Date Date Format: MM slash DD slash YYYY Full NameEmail AddressBus PhonePrivate PhoneFax No.Occupation/Bus/Industry/TradeWhat is your Australian Business Number (ABN)?Name any other interested partyCapacityAddressIs there any other Insurance in force which would cover this in whole or partYesNoIf Yes, please advise in the space provided.Insurer’s NamePolicy DetailsAre you registered for GST?YesNoTo what extent are you registered to claim an Input Tax Credit on the GST applicable to the premium?Description of loss or damageTo assist in assessing the loss, the following information is requested.Description 1Date of LossTimeDescriptionSum Claimed $Date of purchaseFrom whom purchasedPurchase Price $Replacement Value $*Input Tax Credit %*Please show the Input Tax Credit you are entitled to claim on the purchase of each item as a percentage of the total GST payable.Description 2Date of LossTimeDescriptionSum Claimed $Date of PurchaseFrom whom purchasedPurchase Price $Replacement Value $*Input Tax Credit %*Please show the Input Tax Credit you are entitled to claim on the purchase of each item as a percentage of the total GST payable.Description 3Date of LossTimeDescriptionSum Claimed $Date of PurchaseFrom whom purchasedPurchase Price $Replacement Value $*Input Tax Credit %*Please show the Input Tax Credit you are entitled to claim on the purchase of each item as a percentage of the total GST payable.Total amount claimed $Details of Loss Damage or OccurrenceDate of Loss / Damage / or OccurrenceTimeWhen was it reported to you? (If applicable)TimePlace and/or premises where it occurredPlease state full details of how loss/damage/or accident occurredPlease describe nature of damage or injuryWhen were the Police notified? (If applicable)TimePolice StationOfficers namePolice Report No.Responsibility/WitnessesIn your opinion was any other person(s) responsible for loss or damage Or cause of the Occurrence?YesNoFull NameAddressBus PhonePrivate PhoneFax No.ReasonsWas there a witness or witnesses to this event?YesNoIf YES, please give full details.Name of WitnessesWitnesses’ AddressBus PhonePrivate PhoneFax No.Insurance HistoryHave you ever previously sustained loss/damage or caused damage or injury to 3rd partiesYesNoIf YES, give details of such losses and amounts involved.Was an Insurance Company involved?YesNoIf YES, please state name of company and year of claim.Have you been convicted of or had any fines or penalties imposed for any criminal offences in the last 10 years?YesNoIf YES, please provide details.PrivacyThe Privacy Act 1988 requires us to tell you that we as broke and the insurer collect your personal and sensitive information in order to calculate your loss and entitlements, determine the insurer’s liability, compile data and handle claims. When handling claims we and the insurer may have to disclose your personal and other information to third parties such as other insurers, reinsurers, loss adjusters, external claims data collectors, investigators and agents, or other parties as required by law. Where you give us information about other persons you must have their consent to this and provide it on their behalf. If not, you must tell us. You have the right to seek access to your personal information and to correct it at any time. Please contact us to advise if any changes are required.Internal Dispute Resolution (IDR) Statement Disputes are not an everyday occurrence. However insurers provide an internal dispute resolution process should any dispute arise. Please feel free to ask for details. If you are not satisfied with the outcome of that process, we will advise you how to contact the insurance industry’s external independent complaints scheme (subject to eligibility).Declaration1. I/We the insured do solemnly and sincerely declare that I/We have complied with the conditions and warranties (if any) of the policy and have not deliberately caused the said loss or damage or sought unjustly to benefit thereby by any fraud or misrepresentation and that the information shown on the form is true and the I/We have not concealed any information relating to this claim. I/We understand that this claim may be refused if the information is untrue, inaccurate or concealed. 2. Further it is understood and agreed that if any property claimed for is subsequently recovered in an undamaged condition I/We will immediately refund the company any sum which may have been paid to me/us in respect of such property. In the event of any property being recovered in damaged condition I/We will immediately hand the same over to the company for disposal as may be agreed. 3. I/We acknowledge that I/We have read and understood the Privacy Act information referred to above and consent to the collection, storage, use and disclosure of personal and sensitive information of all persons affected by this claim. 4. I/We acknowledge that if I/We do not agree to the collection of this personal and sensitive information, then the broker and the insurer will be unable to process my/our claim.Please provide bank details in order for your claim payment to be settled via EFT.BSB Number:Bank Account Number:Name of Bank:Account Holder Name:Please type your name below to agree to our terms CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.