Full Name* First Last Email* Address* Street Address Bus PhonePrivate PhoneFax No.Occupation/Bus/Industry/TradeName any other interested partyHow interestedAddress Street Address Policy NumberDue DateIs there any other Insurance in force which would cover this in whole or part?*YesNoPlease adviseInsurer’s NamePolicy DetailsWhat is your Australian Business Number (ABN)?Are you registered for GST?*YesNoTo 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 Date Format: MM slash DD slash YYYY TimeWhen was it reported to you (if applicable)? Date Format: MM slash DD slash YYYY TimePlace and/or premises where it occurredPlease state full details of how loss/damage/or 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?*YesNoPlease give details.TimePolice StationOfficers namePolice Report No.Has the loss been advertised?*YesNoGive 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?YesNoName First Last Address Street Address Bus PhonePrivate PhoneFax No.ReasonsWas there a witness or witnesses to this event?*YesNoDetailsName of WitnessesWitnesses’ Address Street Address Bus 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 partiesYesNoGive details of such losses and amounts involved.Was an Insurance Company involved?YesNoPlease 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?YesNoPlease provide details.CAPTCHA