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Machinery Breakdown/Fusion 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
		* Company Name
Name		* Surname
* 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	* Specify amount claimed:	%

The Appliance or Motor
Type of appliance (Motor, etc)
Maker's name
Model
Serial No.
KW watts
Voltage
RPM
Open/Sealed
Appliance purchased from
Date of purchase
Purchase price
Replacement price
Age of unit
Age of motor
Has the motor fused previously?	No Yes
Is the motor under manufacturer's warranty?	No Yes
If yes, please give details

The Incident
Date of damage	dd/mm/yyyy
Time	AM PM
Place
Details of damage
Cause of damage
Where can motor be inspected?
Have you paid the repair account?	No Yes
If yes, amount
To whom

It is important to note that the company may not be liable for: Depreciation, loss of use, wear and tear, hire of loan motors. Replacement of worn and/or broken bearings or switchgear or other mechanical damage. Flushing or recharging refrigerant. Destruction or damage to: lighting or heating elements, fuses or protective devices, an electrical contact at which sparking or arcing occurs in ordinary working. Rectifier, radio, television, amplifying or electrical equipment of any description.
(If spoilage of frozen goods is insured)
Did spoilage of frozen goods occur?	No Yes
Please attach invoices	(max 100 KB)
Where are the goods now?
What was the value of the goods

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