General Claim Form

  • General Details of Loss / Damage

  • Details of Claim

    (YES is required for all malicious damage/burglary claims)
  • Details of person causing damage

    (if applicable)
  • Details of repair work and/or replacement:

  • (If repair/replacement has been carried out, please attach invoice, alternatively attach quotation for repair/replacement)
    List item lost, stolen or damagedOwner of itemIf known: Date, name & address of company where item purchasedPurchase price ($)Input tax credit you can claim on the purchase of these items as a % of the total GST payableAmount claimed ($) 
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  • Electronic Funds Transfer Details

  • Following insurers approval of your claim, should you wish to have your funds transferred directly into your bank account, please provide the following details.

  • Important Notice

  • I hereby declare the above statements and particulars to be true and correct and I make this declaration on the basis that I have delegation of power to sign for and on the behalf of the Insured.