Burglary Theft Money Insurance Claim Full Name First Last Email Address Street Address City State Post Code Business Phone Private Phone Fax No. Occupation/Business/Industry/Trade Name any other interested party How interested Address Street Address City State Post Code Policy Number Due Date Is there any other Insurance in force which would cover this in whole or part? Yes No Please advise Insurer’s Name Policy Details What is your Australian Business Number (ABN)? Are you registered for GST? Yes No To what extent are you entitled to claim an Input Tax Credit on the GST applicable to the premium? (%)*Details of Loss Damage Or OccurrenceDate of Loss / Damage / or Occurrence MM slash DD slash YYYY Time When was it reported to you (if applicable)? MM slash DD slash YYYY Time Place and/or premises where it occurred Please state full details of how loss/damage/accident occurredPlease describe nature of damage or injuryWhere was entry gained into the premises?How was entry gained into the premises?Are there any signs of forced entry? Yes No Please give details.Time Police Station Officers name Police Report No. Has the loss been advertised? Yes No Give Particulars and send a copy of the advertisement.When was the property last seen by you?At the time if the loss, how long had the premises been unoccupied?For money losses – where on premises, was the money taken?In your opinion was any other person(s) responsible for loss or damage or cause of the Occurrence? Yes No Name First Last Address Street Address City State Post Code Business Phone Private Phone Fax No. ReasonsWas there a witness or witnesses to this event? Yes No DetailsName of Witnesses Witnesses’ Address Street Address City State Post Code Business Phone Private Phone Fax No. Description of property loss or damageDescription 1Description 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 $ Description 2Description 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 $ Description 3Description 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 $ Insurance HistoryHave you ever previously sustained loss/damage or caused damage or injury to 3rd parties Yes No Give details of such losses and amounts involved.Was an Insurance Company involved? Yes No 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 Please provide details.
