Landlord Claim Form
1. Insured Details
Please ensure you complete this form with as much detail as possible
Insured Name
Phone No
*
E-mail
*
example@example.com
Policy Number
Are you registered for GST
Yes
No
Do you have an ABN
Yes
No
If yes please provide ABN
2. Loss Details
If the tenant is not at fault, you do not need to supply tenant deails
Date of Loss
*
-
Day
-
Month
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Tenant Details
*
First Name
Last Name
Tenant Phone No
*
Tenant Email
*
example@example.com
Please tick loss type that applies to this claim
*
Fire or explosion
Pet damage
Water damage
Theft
Accidental damage
Storm or rainwater
Impact
Electric motor burnout
Malicious/deliberate damage
Please provide full details of loss
*
Please include the following documentation to support your claim
Repair or Replacement Quotes
Proof of ownership i.e receipts, warranty cards, photos etc.
Photos of damage
Attach relevant documentation here
Browse Files
Drag and drop files here
Choose a file
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3. Electronic Funds Transfer Details
Details
Financial Instituion / Bank
Account Name
BSB (6 digits)
Account Number (max 9 digits)
4. Declaration
Signature
Clear
Name
First Name
Last Name
Date & Time
Submit
Should be Empty: