Incident & Claim Notification

Incident & Claim Notification

Capital Expenditure
Before you complete this form, please take some time to understand the following and undertake the necessary tasks as required:
- take all reasonable precautions and steps to minimise any further damage or loss to the property.
- obtain your insurer's consent before any repairs are commenced.
- do not dispose of any property that you intend to include in an insurance claim without your insurer's consent.
- if a Third Party holds you responsible for their loss, ask them to put their complaint and any claim they may have in writing.
- do not admit liability or fault to any Third Party and do not disclose that you may have insurance in place.
- failure to notify a matter immediately after an Event or when you first become aware of such circumstances may adversely effect the outcomes of any insurance claim you may make.
- the completion and submission of this notification form will send an alert to your Broker, who will then notify your Insurer on your behalf. Please contact your Broker if you have any questions about the completion of this notification and/or the status of any insurance claim that may result.
Please note that the above does not in any way derrogate from any other rights and responsibilities you may have under your Policy and at law.
Location of Incident*
Person Completing the Form
VRP Asset ID*
Policyholder Name*
Full Name/Company Name
Primary Contact*

First NameLast Name
Primary Contact Email*
example@example.com
Primary Contact Phone Number*
Please include area code if landline (e.g. 02 9876 5432)
What is your role? *
If "Other", please advise
Role
Is the person completing this form someone other than the Primary Contact?*

YesNo
Person completing form*

First NameLast Name
What is your role? *
If "Other", please advise
Role
What is your phone number?*
Please include area code if landline (e.g. 02 9876 5432)
What is your email?*
example@example.com
Event Severity
Please indicate if this Event is Minor, Moderate or Major.

If two or more ratings apply, please choose the most severe.

For example, if a Third Party has suffered a minor injury requiring First Aid only (Minor), but has also made a public liability claim for $30,000 (Moderate), you would classify the severity as Moderate.
Using the above classifications, how severe is this incident?*

Near MissMinorModerateMajor
The Event
Type of Event*

EnvironmentalProperty DamageProperty Damage - Theft or Malicious DamageDamage to Someone else’s propertySomeone is Injured
Cause*
Please select one
Consequence*
Please select one
If there is an injury to someone, is this injury any of the following?

DeathSevere TraumaSevere BurnsBrain InjuryLoss of EyesightActual or Potential Spinal InjuryLoss of LimbsFracture or Torn ligamentInjury to a child
Date of Incident*

DayMonthYearHourMinutesAM/PM Option
Date you first became aware of issue if different to Date of Incident*

DayMonthYearHourMinutesAM/PM Option
Incident Description*
Please describe the events leading up to and including the Incident.
Photo & Video Evidence
Please provide photographic and video evidence of this incident.

Please also ensure that all images are clear and show both wide-angled and close-up views of any damage and/or loss where appropriate.
Upload photos
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Upload video or CCTV footage

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Upload Additional Report(s) e.g. cleaners or security report

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The Claim (for primary contact to complete)
Are there indications theThird Party has intention to seek financial compensation for any property damage or personal injuries?*

YesNoUnknown
Estimated cost of claim*
Claims Schedule
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Upload original receipts
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Third Party Details
A Third Party is:
- a Claimant who alleges to have suffered an injury, loss or damage;
- another party who is responsible for causing the loss or damage; OR
- a Witness to the event.
Is a Third Party involved in these circumstances?*

YesNoUnknown
Third Party Details
Upload photos of Third Party's ID e.g. Drivers Licence

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Police Notification
Have the Police been notified of this Event?*

YesNoNot applicable
Date reported to Police*

DayMonthYear
Name of Police Officer

PrefixFirst NameLast Name
Which Police station did you notify this Event?
Police report number*

Insurer Notification (primary contact to complete)
Based on the information you have just reported, would you like to notify your Insurer of this Event?*

YesNoNot yet
NOTE:

A positive response to this question will trigger an alert to your Broker, who will then notify your Insurer and manage your claim on your behalf

Anything else?
Before you finish, is there any additional information or comments that you would like to make?
Upload any additional information

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Declaration
By submitting this form for review, you hereby declare that:

To the best of my knowledge and belief the details given are true, correct and complete in every respect.

I understand that if an incident or claim is intentionally exaggerated or fraudulent, it may be refused and no payments will proceed.

I confirm that I have read and understood the Privacy Statement and consent to the collection, storage, use and disclosure of personal and sensitive information to all persons effected by this Event.

I understand that if I do not agree to the collection of this personal information then my broker and/or insurer(s) it acts as agents for will be unable to process a claim in the event that I want to proceed in this regard.
Contractor Appointment (for Primary Contact to complete)
Would you like to engage a contractor(s) to quote for any works?*

YesNo
Should be Empty: