Saturday, 19 May 2012
Banner
Property Claim Form

  1. Please click here for important information on the Property Claim Form

  2. 1. Policy Details

  3. Full Name(s) of Insured:
    Invalid Input
  4. Address of Insured:
    Invalid Input
  5. Post Code
    Invalid Input
  6. Telephone A/H
    Invalid Input
  7. Telephone B/H
    Invalid Input
  8. Email Address(*)
    Invalid Input
  9. Policy No:
    Invalid Input
  10. Expiry Date:
    Invalid Input
  11. Sum Insured: $
    Invalid Input

  12. GST Details:

  13. Are you registered for GST Purposes?
    Invalid Input
  14. ABN No:
    Invalid Input
  15. To what extent are you entitled to claim an Input Tax Credit for this policy? (%)
    Invalid Input
  16.  

  1. 2. General Details Of Loss / Damage

  2. Location of loss/damage
    Invalid Input
  3. Actual date of loss/damage
    Invalid Input
  4. Approx time of loss/damage
    Invalid Input
  5. Are you the owner of the lost/damaged property?
    Invalid Input
  6. (If no, please state name(s) and address(s) of all other parties and their interest in the property):
    Invalid Input

  7. Was the lost/damaged property:

  8. (i) subject to a Lease or an Agreement?
    Invalid Input
  9. (ii) covered under another insurance policy?
    Invalid Input
  10. (If yes to either/both, please give details)
    Invalid Input
  11. What steps have been taken to recover the lost property or minimise damage to the property?
    Invalid Input
  12. Describe as fully as possible the circumstances and cause of the loss/ damage.
    Invalid Input
  13. How was the loss/damage discovered?
    Invalid Input
  14.  
  1. Were the Police notified?
    Invalid Input

  2. If yes, please state):

  3. (i) date of report
    Invalid Input
  4. (ii) approx. time of report:
    Invalid Input
  5. (iii) Name of Police Station:
    Invalid Input
  6. (iv) Police Event Number:
    Invalid Input
  7. (v) Name of Police Officer:
    Invalid Input
  8. Has any property been recovered?
    Invalid Input
  9. (If yes, please give details)
    Invalid Input
  10. Was any other party responsible for the loss/damage?
    Invalid Input
  11. (If yes, please give details)
    Invalid Input
  12. Has anyone been charged for the loss/damage?
    Invalid Input
  13. (If yes, please give details)
    Invalid Input
  14.  

  1. 3. Complete This Section For Personal Valuables / Burglary / Theft:

  2. How were the premises entered?
    Invalid Input
  3. Were the premises occupied at the time of loss?
    Invalid Input

  4. (If no, please state):

  5. (i) date last occupied
    Invalid Input
  6. (ii) approx. time last occupied
    Invalid Input

  7. 4. Complete This Section For Fire / Damage To Premises

  8. Who was in the premises at the time of damage?
    Invalid Input
  9. For what purpose?
    Invalid Input

  10. 5. Complete This Section For Transit Loss / Personal Baggage

  11. Total value of goods carried ($)
    Invalid Input

  12. Note: Personal baggage claims must be accompanied by the original Policy document

  13. Name of vessel or steamer
    Invalid Input
  14. If travelling by road/air/rail, please advise name of carrier and tour agent
    Invalid Input
  15.  

  1. 6. Statement Of Claim

  2. Property/Articles lost, stolen, damaged or destroyed

  3. 1. Description
    Invalid Input
  4. Date of Purchase
    Invalid Input
  5. Purchase Price
    Invalid Input
  6. Replacement Cost
    Invalid Input
  7. Net Amount Claimed
    Invalid Input
  8. 2. Description
    Invalid Input
  9. Date of Purchase
    Invalid Input
  10. Purchase Price
    Invalid Input
  11. Replacement Cost
    Invalid Input
  12. Net Amount Claimed
    Invalid Input
  13. 3. Description
    Invalid Input
  14. Date of Purchase
    Invalid Input
  15. Purchase Price
    Invalid Input
  16. Replacement Cost
    Invalid Input
  17. Net Amount Claimed
    Invalid Input
  18. 4. Description
    Invalid Input
  19. Date of Purchase
    Invalid Input
  20. Purchase Price
    Invalid Input
  21. Replacement Cost
    Invalid Input
  22. Net Amount Claimed
    Invalid Input
  23. 5. Description
    Invalid Input
  24. Date of Purchase
    Invalid Input
  25. Purchase Price
    Invalid Input
  26. Replacement Cost
    Invalid Input
  27. Net Amount Claimed
    Invalid Input

  28. Declaration

    I/We, the undersigned claimant(s) hereby declare that the foregoing statements and particulars of the claim are true and correct and that I/We have not withheld any information relevant to this claim. I expressly agree that the information given by me is provided with my full knowledge and consent and further agree to hold harmless and indemnify Action Insurance Brokers Pty Ltd, its Employees and Representatives in the event of any action or matter that may be taken by any party pursuant to the Privacy Act 1988 (Cth). I/We acknowledge that I/we have read and understood the paragraphs accompanying this proposal headed “Your Privacy”. In submitting this form, I acknowledge that I may receive documentation from Action Insurance Brokers P/L by email. I further agree that Action Insurance Brokers P/L may from time to time send me important information about new insurance products and services.

  29. I/We agree with the above statement(*)
    Invalid Input
  30. Submit