Domestic Property Claim Form

General Details of Loss
Location of loss/ damage*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Actual date of loss / damage *

MonthDayYear
Date
Approximate time of loss / damage *

Hour Minutes

AM/PM Option
Was the lost/damage property subject to a Lease or an Agreement?

YesNo
Was the lost/damage property covered under another insurance policy?

YesNo
If YES to either or both, please give details:
What steps have been taken to recover the lost property or minimise damage to the property?
Describe as fully as possible the circumstances and cause of loss / damage.

Complete this Section for Transit Loss / Personal Baggage
Total value of goods carried $
Note: Personal baggage claims must be accompanied by the original Policy document.
If travelling by road/ air/ rail, please advise the name of carrier and tour agent.

Type a question

	Description of Property / Article lost, stolen, damaged or destroyed	Date of Purchase	Purchase Price $	Replacement Cost $	Net Amount Clamed $
1
2
3
4
5
6
7
8

Complete this Section for ALL Claims - ABN Details
Are you a registered business?

YesNo
ABN Number
What percentage of GST in your premium did you claim as an Input Tax Credit for the period of insurance in which this loss occurred? %
File Upload (e.g. invoices, images etc.)

Cancelof

Type a question

	Machine / Appliance	Maker	Date of Purchase	H.P. of Motor	Name of Repairer Invoice/Quote Attached	Cost of Repairs
1
2
3
4
5
6
7
8

Total repairs $
Note: To Avoid delay, attach invoice giving the separate items of costs as certain items may not be claimable
Less Excess $
Net amount claimed $

Please complete for THIRD PARTY CLAIMS
Details of injury or damage to third parties:
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Nature and extent of injuries/damage:
Has the third party any relationship to you (e.g. relative, employee)?
Have you received any correspondence from third parties? If so, please enclose them with this form.
Have you made any admission of liability?
Should be Empty:

	Description of property for which loss is claimed	Date of Purchase or Acquisition	Original Cost	Value at time of Loss- allowing for reasonable Depreciation	Value of Salvage (if any)	Amount of Loss or Damage Claimed $
1
2
3
4
5
6
7
8

General Details of Loss