Elders Request Form
New job request for ACG
Elders Contact Details
Name
*
First Name
Last Name
Email
*
example@example.com
Contact Number
*
Please enter a valid phone number.
Format: (0000) 000-000.
Elders Office
*
Elders Reference Number
*
Preferred Contact Method
*
Email
Phone
Insured Details
Company Name
Insured Name
*
Insured Contact No.
*
Please enter a valid phone number.
Format: (0000) 000-000.
Insured Email
*
example@example.com
Secondary Contact Name
Secondary Phone No.
Please enter a valid phone number.
Format: (0000) 000-000.
Is there another contact for onsite access?
Yes
No
Who is the onsite contact?
*
Property Manager, Tenant, Onsite staff
Onsite Contact Name
*
Onsite Contact Phone No.
*
Please enter a valid phone number.
Format: (0000) 000-000.
Site Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the postal address the same as site address?
Yes
No
Optional Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Claim Details
Policy Number
*
Claim Number
Job Details
Cause of damage
*
eg. storm, burglary, impact, hail, ect
Date of Loss
*
-
Month
-
Day
Year
Date
Level of cover
*
Building
Contents
Building & Contents
Number of storeys
*
Single
Double
Multi
Unit
Additional notes
Claim circumstances
Related attachments/images
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Services Required
*
Quote / Assessment
Make Safe
Specialist Report
Why type of specialist report do you require?
*
Submit
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