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Burglary Theft Money Insurance Claim
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Burglary Theft Money Insurance Claim
Burglary Theft Money Insurance Claim
Full Name
First
Last
Email
Address
Street Address
City
State
Post Code
Bus Phone
Private Phone
Fax No.
Occupation/Bus/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 Occurrence
Date of Loss / Damage / or Occurrence
Date Format: MM slash DD slash YYYY
Time
When was it reported to you (if applicable)?
Date Format: MM slash DD slash YYYY
Time
Place and/or premises where it occurred
Please state full details of how loss/damage/or accident occurred
Please describe nature of damage or injury
Where 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
Bus Phone
Private Phone
Fax No.
Reasons
Was there a witness or witnesses to this event?
Yes
No
Details
Name of Witnesses
Witnesses’ Address
Street Address
City
State
Post Code
Bus Phone
Private Phone
Fax No.
Description of property loss or damage
Description 1
Description
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 2
Description
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 3
Description
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 History
Have 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.
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