Burglary Theft Money Insurance Claim Full Name First Last Email Address Street Address City State Post Code Business PhonePrivate PhoneFax No.Occupation/Business/Industry/TradeName any other interested partyHow interestedAddress Street Address City State Post Code Policy NumberDue DateIs there any other Insurance in force which would cover this in whole or part? Yes No Please adviseInsurer’s NamePolicy DetailsWhat 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 TimeWhen was it reported to you (if applicable)? MM slash DD slash YYYY TimePlace and/or premises where it occurredPlease 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.TimePolice StationOfficers namePolice 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 PhonePrivate PhoneFax No.ReasonsWas there a witness or witnesses to this event? Yes No DetailsName of WitnessesWitnesses’ Address Street Address City State Post Code Business PhonePrivate PhoneFax No.Description of property loss or damageDescription 1DescriptionSum Claimed $Date of PurchaseFrom whom purchasedPurchase 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 2DescriptionSum Claimed $Date of purchaseFrom whom purchasedPurchase 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 3DescriptionSum Claimed $Date of purchaseFrom whom purchasedPurchase 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.
