General Insurance Claim Policy Number Due Date MM slash DD slash YYYY Full Name Email Address Business PhonePrivate PhoneFax No.Occupation/Business/Industry/Trade What is your Australian Business Number (ABN)? Name any other interested party Capacity Address Is there any other Insurance in force which would cover this in whole or part Yes No If Yes, please advise in the space provided. Insurer’s Name Policy Details Are you registered for GST? Yes No To what extent are you registered to claim an Input Tax Credit on the GST applicable to the premium?* Description of loss or damageTo assist in assessing the loss, the following information is requested.Description 1Date of Loss Time Description Sum Claimed $ Date of purchase From whom purchased Purchase Price $ Replacement Value $ *Input Tax Credit % *Please show the Input Tax Credit you are entitled to claim on the purchase of each item as a percentage of the total GST payable.Description 2Date of Loss Time Description Sum Claimed $ Date of Purchase From whom purchased Purchase Price $ Replacement Value $ *Input Tax Credit % *Please show the Input Tax Credit you are entitled to claim on the purchase of each item as a percentage of the total GST payable.Description 3Date of Loss Time Description Sum Claimed $ Date of Purchase From whom purchased Purchase Price $ Replacement Value $ *Input Tax Credit % *Please show the Input Tax Credit you are entitled to claim on the purchase of each item as a percentage of the total GST payable.Total amount claimed $ Details of Loss Damage or OccurrenceDate of Loss / Damage / Occurrence Time When was it reported to you? (If applicable) Time Place and/or premises where it occurred Please state full details of how loss/damage/accident occurredPlease describe nature of damage or injuryWhen were the Police notified? (If applicable) Time Police Station Officers name Police Report No. Responsibility/WitnessesIn your opinion was any other person(s) responsible for loss or damage Or cause of the Occurrence? Yes No Full Name Address Business PhonePrivate PhoneFax No. ReasonsWas there a witness or witnesses to this event? Yes No If YES, please give full details.Name of Witnesses Witnesses’ Address Business PhonePrivate PhoneFax No.Insurance HistoryHave you ever previously sustained loss/damage or caused damage or injury to 3rd parties Yes No If YES, give details of such losses and amounts involved.Was an Insurance Company involved? Yes No If YES, please state name of company and year of claim.Have you been convicted of or had any fines or penalties imposed for any criminal offences in the last 10 years? Yes No If YES, please provide details.Please type your name below to agree to our terms CommentsThis field is for validation purposes and should be left unchanged.
