General Claim Form
Name
*
First Name
Last Name
Email
example@example.com
Insured Name
*
Address of incident
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
ABN
Are you registered for GST?
*
Yes
No
Incident details
Date of Incident
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Approx Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Does the claim relate to
*
Domestic Home Claim
Equipment Breakdown
Theft Only
Glass Only
Glass and Theft
Commerial Property Damage
Other
Police Report Number
Are Urgent Repairs or a Make safe required?
*
Yes
No
Unsure
Have you obtained a repair/replacement quote?
*
Yes
No
Have Repairs been completed?
*
Yes
No
Was there any loss of stock as a result of the breakdown?
*
Yes
No
Has there been damage to any glass?
*
Yes
No
How did the incident occur?
*
Ie how did they gain entry etc
What Damages have you suffered?
*
Do you have a list of the Damage Items ?
Rows
Item Description
Purchase Price
Repalcement Cost
Proof of Ownership (Y/N)
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Item 7
Item 10
Item 11
Do you want a cash settlement?
*
Yes
No
Payment details
Account Name
*
BSB
*
Account Number
*
Any other details
File Upload - Photos or invoices
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