Machinery Breakdown / Fusion Insurance Claim Name of insuredAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email OccupationDate of Birth Private PhoneBusiness PhonePolicy No.Date Time : HH MM AM PM What is your Australian Business Number (ABN)?Are you registered for GST?YesNoTo what extent are you entitled to claim an Input Tax Credit on the GST applicable to the premium?Where did the loss occur?Date of loss Describe as fully as possible how loss occurredDo you consider any other party responsible for the loss?YesNoIf YES, Please state why.Are you the sole owner of the property lost or damagedYesNoIf NO, give details of other owners or part owners.Do you hold any other insurances under which a claim for this loss may be lodged?YesNoIf YES, please give details.Name and type of appliance to which motor is attachedWho was it purchased from?Date of purchase PriceIs the motor under manufactures warranty?YesNoIf YES, has a claim been made under the warranty?Electrical Repairers ReportMake of MotorHpSerial No.VoltageRMPOpen or sealedAge Details of DamageCause of DamagePlease attach actual repair accountRepair Costs Windings$Compressor$Other Repairs$ 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 of GoodsQuantityCostAmount Claimed*Input Tax Credit % Repairs having been completed to my satisfaction I hereby claim the amount ofPrivacy The 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 suchas 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). Declaration (must be completed) 1. 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.Name First Last Date I AGREEHow To Get Quick Action On Your Claim1. Complete the attached form and return to our office. If an assessor is appointed, give them the forms.2. Attach all original quotations or invoices obtained for replacement of r repair to the damaged or missing property. Photocopies are not accepted as a rule.3. Attach original valuations and receipt of purchases whenever possible4. Advise the Police immediately in the event of loss by burglary, housebreaking, theft, suspected malicious damage. Also make sure the premises are secure to avoid further incidents.Note: Police reports are very slow so if you can obtain one at the time the report is taken, then this will save valuable time or at least obtain a copy or report number.5. Attach any letter of demand or other correspondence that you may receive from any Third Party.6. Do not make any admission of liability for loss or damage caused by you to the Third Parties.WHAT WE WILL DO – IF THE PAPERWORK IS CORRECT AND COMPLETE: -Submit the claim form to the InsurerIf the claim has not been paid within 30 days we will contact the Insurer and then advise you accordinglyWe will then follow up the claim when necessary until settlement is reached, however, please feel free to call at any timeWHAT AN ASSESSOR WILL DO:-An assessor is an independent person who is appointed by the Insurer for the expertise in helping you finalise a larger or more difficult claimThey will interview and obtain details of a loss and arrange for quotes and prepare the necessary paperworkThe assessor is your contact pointThe assessor will write a report to the Insurer recommending a course of actionThis can take time depending on their work load and Police ReportsThe Insurer will not act until these reports are received and although not bound by the assessor recommendations, the Insurers usually accept these reportsIf you are unhappy with any aspect of the claim, advise the assessor. If he is unable to correct the problem then contact us immediately. We will not know of any problem without being advised.If you are unhappy with the assessor’s responses, contact us immediately.CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.