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Event Claim Notification
1. Policy holder information
Policy holder name
What is your policy number?*
Are you a Business or an Individual?*
Business
Individual
Business Name (optional)
First name*
Surname*
Policy holder address
Street Number
Street Name
Street Type
- Select -
Avenue
Boulevard
Circuit
Close
Corner
Court
Crescent
Drive
Gardens
Heights
Highway
Parade
Parkway
Road
Street
Way
----------
Alley
Approach
Arcade
Brow
Bypass
Causeway
Circus
Copse
Cove
End
Esplanade
Flat
Freeway
Frontage
Glade
Glen
Green
Grove
Lane
Link
Loop
Mall
Mews
Packet
Park
Place
Promenade
Reserve
Ridge
Rise
Row
Square
Strip
Tarn
Terrace
Thoroughfare
Track
Trunkway
View
Vista
Walk
Walkway
Yard
Suburb*
Postcode*
State / Territory
- Select -
NSW
ACT
VIC
QLD
NT
SA
WA
TAS
Your Contact Details
Are you the policy holder?*
Yes
No
First name*
Surname*
Mobile
Home Phone
Work Phone
Email*
Your preferred method of contact*
Mobile
Phone
Email
Best time of day to contact you
AM
PM
Nominate a representative to speak on your behalf
2. Claim Details
Event Information
What is the cause of loss or damage?
- Select -
Accidental damage
Accidental glass breakage
Accidental loss
Escape of Liquids (formerly Burst, Leakage, Overflow)
Earthquake
Fire, Explosion
Flood
Impact
Lightning
Malicious damage (including vandalism)
Motor burnout, Fusion
Storm, Rainwater
Tell us in detail what happened*
Tell us in detail what has been damaged*
Have your content items suffered any loss or damage?
Yes
No
Photo of damage
Choose File
Is your property secure/livable?
Yes
No
N/A
Have you taken any action to minimise loss?
Yes
No
N/A
Do you require assistance securing the property?
Yes
No
N/A
Do you require emergency accommodation?
Yes
No
N/A
Event details
State in which the event occurred*
- Select -
NSW
ACT
VIC
QLD
NT
SA
WA
TAS
Date and time the event occurred*
HH
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
MM
0
05
10
15
20
25
30
35
40
45
50
55
When did you discover the damage or loss?*
Is this the only insurance policy that covers this property?
Yes
No
Other insurance company name
Other insurance company policy number
Have you notified the insurer?
Yes
No
N/A
Was your home occupied at the time of the damage or loss?
Yes
No
When was your home last occupied?
Damaged Items
Please list the main items below. One of our Claim Representatives will be in contact with you, to gather further information regarding your claim.
Item 1
Description
Make
Model
Model Number
Age of item
Purchased From
Original Purchase Price
Proof of ownership
- Select -
Receipts
Delivery Dockets
Manuals
Credit Card Statements
Warranties
Service Records
Photos
No Proof
Document / photo
Item 2
Description
Make
Model
Model Number
Age of item
Purchased From
Original Purchase Price
Proof of ownership
- Select -
Receipts
Delivery Dockets
Manuals
Credit Card Statements
Warranties
Service Records
Photos
No Proof
Document / photo
Item 3
Description
Make
Model
Model Number
Age of item
Purchased From
Original Purchase Price
Proof of ownership
- Select -
Receipts
Delivery Dockets
Manuals
Credit Card Statements
Warranties
Service Records
Photos
No Proof
Document / photo
Item 4
Description
Make
Model
Model Number
Age of item
Purchased From
Original Purchase Price
Proof of ownership
- Select -
Receipts
Delivery Dockets
Manuals
Credit Card Statements
Warranties
Service Records
Photos
No Proof
Document / photo
Item 5
Description
Make
Model
Model Number
Age of item
Purchased From
Original Purchase Price
Proof of ownership
- Select -
Receipts
Delivery Dockets
Manuals
Credit Card Statements
Warranties
Service Records
Photos
No Proof
Document / photo
Reported to Police or the Fire Brigade
Who was the incident reported to?
Police
FireBrigade
Did the Police or Fire Brigade attend?
Yes
No
Name of Officer
Police station the officer was from
Event/Report number if provided
Fire station that attended
Was there anybody injured?
Yes
No