JUMP TO:Motor Claim FormLiability Incident Notification FormIndustrial Special Risks FormPlant and Machinery FormStrata Claim FormProperty Claim FormLandlord Claim FormHome and Contents Claim Form Motor Claim POLICYHOLDER DETAILS Policy Number * Insured Name * First Name Last Name Phone * Country (###) ### #### Email * Vehicle Year, Make and Model * Vehicle Registration Number * Hire Car Coverage Market Value or Sum Insured? Market value Sum insured Fleet Number (if commercial) DRIVER DETAILS Driver's Name * First Name Last Name Driver's Date Of Birth * MM DD YYYY Driver's Licence No. * Driver's Licence Class * Driver's Licence Expiry Date * MM DD YYYY Years Licence Held * Any traffic convictions or accidents in last 5 years? * Yes No Any criminal offences, fines or penalties in last 10 years? * Yes No Alcohol or drugs in the 12 hours prior to accident? * Yes No Breath or blood test for alcohol or drugs undertaken? * Yes No Refused to undergo breath/blood test? * Yes No ACCIDENT DETAILS Vehicle Use * Business Private Date of Accident * MM DD YYYY Time of Accident * Hour Minute Second AM PM Accident Location * Address 1 Address 2 City State/Province Zip/Postal Code Country Describe how the accident happened. * Do you have any dashcam footage available that captured the accident? * Yes No Who do you consider at fault? * Myself Third Party *If you are at fault, advise the other driver to get a quote and provide your policy number* Were there any witnesses? * Yes No Did police attend? * Yes No If yes, Police Report Number: Was your vehicle damaged? * Yes No Is the vehicle driveable? * Yes No Current Location of Vehicle * Address 1 Address 2 City State/Province Zip/Postal Code Country ADDITIONAL INFORMATION Do you have a repairer you wish to use? Yes No DAMAGE TO OTHER VEHICLE/PROPERTY If you have information regarding the Third Party, please fill out all available details below. Other Driver's Name First Name Last Name Other Driver's Email Other Driver's Phone number Country (###) ### #### Other Driver's Address Other Driver's Licence Number Other Driver's Vehicle Year, Make & Model: Other Driver's Registration Number: Other Driver's Insurance Company / Claim Number: DOCUMENTATION CHECKLIST Do you have any of the following documentation? Photos of your damaged vehicle Photos of other party/property damage Tow invoice/receipt Repair quotation Letter of demand Any other relevant documents Thank you! Liability Incident Notification Form POLICYHOLDER'S DETAILS Insured Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Policy Number * CLAIMANT'S DETAILS Claimant's Name * First Name Last Name Claimant's Date Of Birth * MM DD YYYY Claimant's Phone Number * DOCUMENTATION CHECKLIST RELATIONSHIP What were you retained or contracted to do? * Have you obtained legal representation to act on your behalf? * Yes No What is your advice as to whether any other person or entity has contributed to the circumstances which have given rise to the claim? * What are your views on liability and the potential value ($) of the claim/circumstance? * In your opinion, how could this matter be best resolved? * Thank you! Industrial Special Risks Form POLICYHOLDER'S DETAILS Insured Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Policy Number * LOSS DETAILS Date of Loss * Or the date you first became aware of the loss. MM DD YYYY Please provide a description of the claim, including the circumstances. * Please provide a description of the loss. Please describe what happened. * Who discovered the loss, theft or damage? * Does any other party have an interest in the property being claimed for? * Yes No Do you know who is responsible for the loss, theft or damage to your property? * Yes No Was this loss, theft or damage reported to the police / fire brigade? * Yes No Is a makesafe required at the property? Yes No Have you obtained quotations for the resultant damage? * Yes No Please provide your nominated EFT details and GST registration details. Thank you! Plant and Machinery Form POLICYHOLDER'S DETAILS Insured Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Policy Number * LOSS DETAILS Date of Loss * Or the date you first became aware of the loss. MM DD YYYY Please provide a description of the claim, including the circumstances. * Please provide a description of the item/s. * Please provide the serial number of the item/s. * Please provide the registration number of the item/s. * Please provide the hours worked/speedo reading of the item/s. * Is the item/s under any financing? * Yes No DRIVER DETAILS Driver/Operator's Name * First Name Last Name Phone Number (###) ### #### Relationship of driver/operator (ie. the insured, employee, contractor, hirer) * Was any other party involved and/or responsible for causing the accident, personal injury or damage? * Yes No What was the third party involvement and why do you consider them responsible? * Has the third party confirmed liability? Yes No Was the third party's damaged property a road registered motor vehicle or item of plant? Yes No Were the police notified? Yes No Please provide your nominated EFT details and GST registration details. Thank you! Strata Claim Form Strata Plan Number * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Policy Number * Nominated contact for all correspondence relating to this claim * Contact's Phone * (###) ### #### Contact's Email * Date of loss * (or the date you first became aware) MM DD YYYY Please provide a description of damages sustained and which room/s have been affected. * Has the cause of the damages been identified? * Yes No Is a makesafe required? * Yes No Please select one of the following options that best describes the damages sustained. * Storm damage Burst pipe Impact damage Fire Malicious damage Do you believe the property is unfit for its intended purpose due to the damages sustained? * Yes No Is the affected unit tenanted? * Yes No Is the affected unit owner occupied? * Yes No Do you have a builder you wish to proceed with? * Please note the insurer may require a breakdown of costs to be provided. Yes No Would you like us to engage a builder attend to inspect the damages? * Yes No Do you hold any other insurances under which a claim for this incident may be made? * Yes No Was there a third party involved? * Yes No Please provide the Strata Plans nominated EFT details and GST registration details. Thank you! Property Claim Form Policyholder's Name * Policyholder's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Policy Number * Date of loss * (or the date you first became aware) MM DD YYYY Please provide a description of damages sustained and which room/s have been affected. * Has the cause of the damages been identified? * Yes No Is a makesafe required? * Yes No Please select one of the following options that best describes the damages sustained. * Storm damage Burst pipe Impact damage Fire Malicious damage Is temporary accommodation required? * Yes No Do you have a builder you wish to proceed with? * Please note the insurer may require a breakdown of costs to be provided. Yes No Would you like us to engage a builder attend to inspect the damages? * Yes No Do you hold any other insurances under which a claim for this incident may be made? * Yes No Was there a third party involved? * Yes No Please provide the Strata Plans nominated EFT details and GST registration details. Thank you! Landlord Claim Form Policyholder's Name * Policyholder's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Policy Number * Date of loss * (or the date you first became aware) MM DD YYYY Please provide a description of damages sustained and which room/s have been affected. * Has the cause of the damages been identified? * Yes No Is a makesafe required? * Yes No Please select one of the following options that best describes the damages sustained. * Storm damage Burst pipe Impact damage Fire Malicious damage Please provide the contact details of the property manager to allow us to obtain the necessary documentation. * Do you have a builder you wish to proceed with? * Please note the insurer may require a breakdown of costs to be provided. Yes No Would you like us to engage a builder attend to inspect the damages? * Yes No Do you hold any other insurances under which a claim for this incident may be made? * Yes No Was there a third party involved? * Yes No Please provide the Strata Plans nominated EFT details and GST registration details. Thank you! Home and Contents Claim Form Policyholder's Name * Policyholder's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Policy Number * Date of loss * (or the date you first became aware) MM DD YYYY Please provide a description of damages sustained and which room/s have been affected. * Has the cause of the damages been identified? * Yes No Is a makesafe required? * Yes No Please select one of the following options that best describes the damages sustained. * Storm damage Burst pipe Impact damage Fire Malicious damage Please provide the best contact details to allow us to obtain any further necessary documentation requested by the insurer. * If there is property damage to your property, do you have a builder you wish to proceed with? * Please note the insurer may require a breakdown of costs to be provided. Yes No Would you like us to engage a builder attend to inspect the damages? * Yes No If contents items have been damaged during this event. Please provide a list of all affected items along with any proof of purchase documentation. Do you hold any other insurances under which a claim for this incident may be made? * Yes No Was there a third party involved? * Yes No Please provide the Strata Plans nominated EFT details and GST registration details. Thank you!
