Property Claim Form

Please click here for IMPORTANT INFORMATION on the Property Claim Form

1. Policy Details

Full Name(s) of Insured:

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Address of Insured:

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Post Code

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Telephone A/H

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Telephone B/H

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Email Address(*)

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Policy No:

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Expiry Date:

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Sum Insured: $

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GST Details:

Are you registered for GST Purposes?

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ABN No:

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To what extent are you entitled to claim an Input Tax Credit for this policy? (%)

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2. General Details Of Loss / Damage

Location of loss/damage

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Actual date of loss/damage

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Approx time of loss/damage

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Are you the owner of the lost/damaged property?

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(If no, please state name(s) and address(s) of all other parties and their interest in the property):

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Was the lost/damaged property:

(i) subject to a Lease or an Agreement?

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(ii) covered under another insurance policy?

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(If yes to either/both, please give details)

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What steps have been taken to recover the lost property or minimise damage to the property?

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Describe as fully as possible the circumstances and cause of the loss/ damage.

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How was the loss/damage discovered?

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Were the Police notified?

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If yes, please state):

(i) date of report

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(ii) approx. time of report:

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(iii) Name of Police Station:

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(iv) Police Event Number:

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(v) Name of Police Officer:

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Has any property been recovered?

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(If yes, please give details)

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Was any other party responsible for the loss/damage?

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(If yes, please give details)

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Has anyone been charged for the loss/damage?

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(If yes, please give details)

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3. Complete This Section For Personal Valuables / Burglary / Theft:

How were the premises entered?

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Were the premises occupied at the time of loss?

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(If no, please state):

(i) date last occupied

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(ii) approx. time last occupied

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4. Complete This Section For Fire / Damage To Premises

Who was in the premises at the time of damage?

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For what purpose?

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5. Complete This Section For Transit Loss / Personal Baggage

Total value of goods carried ($)

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Note: Personal baggage claims must be accompanied by the original Policy document

Name of vessel or steamer

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If travelling by road/air/rail, please advise name of carrier and tour agent

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6. Statement Of Claim

Property/Articles lost, stolen, damaged or destroyed

1. Description

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Date of Purchase

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Purchase Price

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Replacement Cost

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Net Amount Claimed

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2. Description

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Date of Purchase

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Purchase Price

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Replacement Cost

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Net Amount Claimed

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3. Description

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Date of Purchase

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Purchase Price

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Replacement Cost

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Net Amount Claimed

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4. Description

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Date of Purchase

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Purchase Price

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Replacement Cost

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Net Amount Claimed

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5. Description

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Date of Purchase

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Purchase Price

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Replacement Cost

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Net Amount Claimed

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Declaration

I/We, the undersigned claimant(s) hereby declare that the foregoing statements and particulars of the claim are true and correct and that I/We have not withheld any information relevant to this claim. I expressly agree that the information given by me is provided with my full knowledge and consent and further agree to hold harmless and indemnify Action Insurance Brokers Pty Ltd, its Employees and Representatives in the event of any action or matter that may be taken by any party pursuant to the Privacy Act 1988 (Cth). I/We acknowledge that I/we have read and understood the paragraphs accompanying this proposal headed “Your Privacy”. In submitting this form, I acknowledge that I may receive documentation from Action Insurance Brokers P/L by email. I further agree that Action Insurance Brokers P/L may from time to time send me important information about new insurance products and services.

I/We agree with the above statement(*)

Yes

No

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Anti-Spam(*)

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