Landlord Insurance Claim Form

Landlords Insurance Claim Form
Name of insured*
Property manager
Contact name*

First NameLast Name
Email*
example@example.com
Phone number*
Please enter a valid phone number.
Insured address*

Street Address

Street Address Line 2

SuburbState

Post Code

GST Details
Is the insured registered for GST purposes?*

YesNo
Insured ABN
Has the insured claimed (or can claim) an input Tax Credit for the GST on your insurance policy?

YesNo
Enter the amount the insured intends to claim if it’s less than 100%

Type of Claim(s) Required
What type of claim(s) will you be submitting?*

All claims (excluding rent default)Rent Default claim

Rent Default Claim
Please attach the residential lease applicable to the claim*

Cancelof
Please attach tenancy ledger or relevant bank statement*

Cancelof
Reason for loss of rent*
Amount of claim for loss of rent*

Cleaning and re-letting expenses should be deducted from the bond as follows:

	Total Cost	Less: Input Tax Credit	Net Cost
General cleaning
Advertising
Re-letting fee
Other (specify)

Total cleaning and re-letting expenses
Net Bond = Bond amount less net expenses
Net claim amount

Payment Details
Do you want payment to be made by electronic funds transfer?*

YesNo
Bank name
Branch
Account name
Account number
BSB
Who should the settlement cheque to be made payable to (name and address)?
Disclosures
Claim Privacy Statement

By continuing, you confirm that you understand and consent to all information disclosed on this claim form to be shared with Risksmart Claims Solutions Pty Ltd (Risksmart, we, us, our).

We collect, use, disclose and handle personal information in accordance with the Australian Privacy Principles under the Privacy Act 1988 (Cth). You can access a copy of our Privacy Policy on our website at http://risksmartclaims.com.au/privacy-policy/.

Your personal information will be used by Risksmart for the purpose of managing your insurance claim. We provide information we collect about any claims you make to your insurer (or anyone your insurer has appointed to assist it to consider your claim, e.g. loss adjusters, medical brokers, solicitors etc) to enable it to consider your claims. Insurers may in turn pass on this information to their reinsurers. Risksmart may also disclose your personal information to witnesses in respect to your claim and to government agencies including the police (where we are compelled by law).

If you do not wish for your personal or sensitive information to be passed onto any of the above listed recipients, please contact us on 02 8297 1722. We note that in the event that you decide not to provide Risksmart with the required information, or you do not consent to the terms of the Privacy Policy or revoke your consent, we may not be able to assess your claim.

If you have any queries about Risksmart’s Privacy Policy, please contact our Privacy Officer at privacyofficer@honan.com.au.

Privacy Consent, Declaration and Authority

I:
- consent to the collection, use and disclosure of my personal information in accordance with Risksmart’s Privacy Policy and this document for the lodgement of my claim. This consent remains valid unless I alter or revoke it by giving written notice to Honan;
- confirm that any information that I supply will be true and correct and that I will not withhold any information likely to affect the assessment of my claim by the insurer;
- Authorise Risksmart to disclose my personal information to the insurer and other third parties referred to above where relevant to the lodgement or assessment of my claim.
Declaration
(lf a firm / company, the following declaration must be made and signed by a member of the firm, so describing him self / herself)

I/We declare that the above answers are true and correct to the best of my/our knowledge and that I/we have not withheld any relevant information that may affect the claim. I/we consent to Risksmart Claims Solutions Pty Ltd using my personal information provided on this form for the purpose of processing my claim.
Signature*

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Name*

First NameLast Name
Position (if a firm/company)
Should be Empty:

Landlords Insurance Claim Form

Tenant Details

Type of Claim(s) Required

Property and Contents Claim

Rent Default Claim

Payment Details

Disclosures

Declaration