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Plate Glass 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:	%

Particulars of Damage
Situation of Glass
Occupied by
State fully the cause of breakage
Date of Breakage	dd/mm/yyyy
When was the Loss or damage reported to you?
Description and size of Glass Broken:
Window, Miror, etc.
Plain sheet, Plate, Tinted, etc.
Size of Glass

Claim Information
Was any person responsible for causing the loss/damage?	No Yes
Name
Address
Post Code

Witnesses
Name
Address
Post Code
In your opinion why is that person responsible for the damage?
Give particulars of any previous breakages (date/cause/insurer)
If the Sign writing is insured, give particulars

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