| Date * |  |
|
| Time | | |
| Name of Insurer * | | |
| Policy Number * | | |
| Insured Name * | | |
| Postal Address * | | |
| Phone Number * | | |
| Mobile | | |
| If registered for GST, please advise ABN Number | | |
| %ITC | | |
| Type of Claim * | | |
| Other type of claim | | |
| Date of Loss * | |
|
| Where did the loss or damage occur * | | |
| How did the damage/loss occur * | | |
| Has the damage been repaired? * | | |
| If yes, has the invoice been paid | | |
| If Burglary, Police report number | | |
| Police Station | | |
| Telephone Number | | |
| Date notified | |
|
| Name of Officer | | |
| How were the premises entered | | |
| If damage is the result of fire - Did fire brigade attend? | | |
| If fusion - please state the type of appliance and age of unit | | |
| If fusion - Please supply a full report from Electrical Contractor | | |
| If swimming pool pump - is the pool above ground? | | |
| I agree that upon submission the information provided is true and correct. * | | |
Property
