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Fire, Storm and Temperst, Water Damage, Breakage Claim Form

The Issue of this Form is not an Admission of Liability by Insurer
* = Required information		Policy #:
Please complete and return this claim form as soon as possible, so that your claim will receive prompt consideration by the Insurers.

The Insured
		* Surname
Other Name		* Company Name
* Address
* Post Code
* Occupation
* Phone Private		* Phone Business
* Fax No.		* Mobile
* Email		* Contact Name
* Are you registered for GST?	No Yes	* What is your ABN?
* Have you claimed an input tax credit on the GST amount applicable to this policy?	No Yes	* Is the amount claimed less than 100% of the GST applicable to the premium?	No Yes
		* Specify amount claimed:	%
* Are you entitled to claim an input tax credit for the repairs or replacement of the vehicle?	No Yes	* Is the amount claimable less than 100%	No Yes
		* Specify amount claimed:	%

Details
Is Insured Owner or Tenant of the building?
What was the Full Value of the Property at Time of Loss or Damage?
Name any other Person or Company having an Interest in the Property, which is the subject of this Claim.
Was there any Insurance, other than the above-mentioned Policy, current or extending to cover the said Property, or any part of it, at the time of the Loss or Damage?	No Yes
Loss or Damage occurred at (Address)
On (Date)	dd/mm/yyyy
Time	AM PM
Type of Loss or Damage (e.g. Fire – Storm & Tempest – Water Damage – Breakage – Loss – Damage)
How did Loss or Damage occur?

Claim History
Have you ever previously sustained a Loss or Damage under a Fire or householder’s Policy?	No Yes
If so, was a claim made upon any Insurance Company?	No Yes
If so, state:
1. Name of Company
2. Nature of Loss or Damage
3. Amount of Claim paid
Is any Third Party to blame for Loss or Damage?	No Yes
If so, who?

STORM and TEMPEST CLAIMS ONLY
What was the damage (Buildings or Contents)?
What damage was caused?
Through what type of opening did wind, rain, or water enter premises?
Did Storm cause this opening?	No Yes
If so, how?

To avoid unnecessary delay in processing your claim, it is important that you attach documentation to support:

ownership of all property claimed, eg. Original invoices, owners manuals, photos, receipts, etc…
the repair / replacement of your loss. Eg. Original invoices, receipts, etc… by trade suppliers / repairers – itemising the precise nature of their quotation or work under taken eg. Size, model, type, age, hours, cost of labour, parts, prices…

Agree No Yes

DECLARATION
                
                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 in no matter 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.
                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 to 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.
                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.
                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.

Agree No Yes

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IPS - Suite 7-8 (first floor)
134 Main St - Osborne Park WA 6017
Phone: (08) 9340 5400 - Fax: (08) 9340 5411
Email: admin@ips.net.au