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General Claim Form

For Domestic or Commercial Losses Including Bulgary/Theft/Money

The Issue of this Form is not an Admission of Liability by Insurer

* = Required information

Policy #:

Please complete this claim form, 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:	%

The Premises
Nature of trade or business
Are the premises owner occupied/rented/leased?
Age of building (year)
Type of premises (eg house/unit/factory/store/office, etc)
If you are a tenant - are you liable for damage under the terms of your lease/tenancy agreement?
Construction (eg brick/wood/fibro, etc)

The Loss
Date of Loss	dd/mm/yyyy
Time	AM PM
Who discovered loss?
Address where loss/damage occurred
Postcode
Phone No.
What type of property has been lost or damaged? (Eg Buildings, content, stock, etc)
Type of damage (eg Storm, water damage, fire, etc)
How did the loss occur?
COMPLETE THIS SECTION FOR STORM DAMAGE CLAIMS ONLY
Through what type of opening did wind, rain or water enter building?
Did a storm cause this opening?	No Yes
If "yes", how?

Claim Information
Was any person responsible for causing the loss/damage?
Name
Address
Postcode
Phone Business
Phone Private
In your opinion why is that person responsible for the damage?

Action Taken (if a police matter)
Which police station was the incident reported to?
When reported?
Name of the police officer
What is the police reference No.
Has any arrest been made?	No Yes
If yes, give details
Is anyone suspected of the loss?	No Yes
If yes, give details
Has any of the property been recovered?	No Yes
If "no", what steps have been taken to recover the stolen property?

Witness
Where there any witnesses to the accident?	No Yes
If yes, please give details
Name
Address
Postcode
Phone Business
Phone Private

Other Interests
Does any person or organisation have an interest in the property, which is the subject of this claim?	No Yes
If yes, please give details
Name
Address
Postcode
Phone No.
Interest (eg Mortgage, Bill of Sale, etc)
Is there another insurance coverage (including Medical Fund) covering the lost/damaged property?	No Yes
If yes, please give details
Insurer
Policy No.
Amount
Address
Postcode

Your Claims History

Has any person covered under this insurance policy ever sustained a loss during the past five years?

No Yes

If “yes”, please give full details including name of previous insurers.

Claimed Loss/Damage

Description and quantity of property for which loss is claimed (Include model No.)	Date of purchase or acquisition	Original purchase price	Deduction for age and use	Where purchased?	Amount being claimed

General remarks (any further information you consider relevant)

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