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Contract Works 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?
* What is your ABN?  
* Have you claimed an input tax credit on the GST amount applicable to this policy?
* Is the amount claimed less than 100% of the GST applicable to the premium?
    * Specify amount claimed:  %  
* Are you entitled to claim an input tax credit for the repairs or replacement of the vehicle?
* Is the amount claimable less than 100%
    * Specify amount claimed:  %  
Particulars of Incident
Date of loss  dd/mm/yyyy  
Defects Liability Period  months
Contract Period (Commenced)  dd/mm/yyyy  
Pratical Completion  dd/mm/yyyy  
What happened? (provide a sketch if appropriate)
What is lost or damaged?
Estimate of amount of Claim
Third Party Liability
Did injuries to third parties occur?
Contact name of injured person
Address
Postcode
Phone Private
Phone Business
Contact name
Was the injured person working on site?
Date of injury  dd/mm/yyyy  
Time of accident
Was hospitalisation required?
What happened?
What injuries were sustained?
Do you consider anyone else responsible for injury (if so why)?
Did third party property damage occur?
Contact name of third party
Address
Postcode
Date of accident  dd/mm/yyyy  
Time of accident
What was the damage?
What is the estimated amount of damage
Do you consuder anyone else responsible for injury (if so why)?
Witnesses
Name addresses an telephone numbers of non-indipendent witnesses
Name addresses an telephone numbers of indipendent witnesses
 

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

Agree

Agree
 
 
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