• General Claim Form

    Please complete this claim form so that we can get your claim moving

  • By submitting this form, you consent to the collection of your personal information for the purpose of assisting with your insurance claim and its disclosure to the relevant insurer to assess and manage your claim. Your information will be handled in accordance with the repX Privacy Policy.

    To avoid delays in the assessment process, please submit the requested information as soon as possible.

  • 1. Policy Details

  • Expiry Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Contact Details

  •  -

  • 2. General Details of Loss/Damage

  • Date of event?*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Is any Third Party to blame for loss or damage?
  • Have you received, or do you anticipate receiving any Third Party demands as a result of this event?
  • Were there any witnesses?
  • Witness Details
  • Were the police notified?*
  • Date of Report
     - -
    2 digit day, 2 digit month, 4 digit year

  • 3. Other Particulars

  • 4. ABN Details

  • Are you a registered business?*

  • 5. Loss / Damage Claims Schedule

  • Please complete for loss of property:
  • Please complete for damage of property:
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    Cancelof

  • 6. Third Party Claims

  • Please complete for Third Party Claims:

  • Have you received any correspondence from third parties?
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  • Have you made any admission of liability?

  • Declaration

  • I, {typeA196} {typeA197}, confirm that the information provided is true and correct to the best of my knowledge and understand it will be provided to the insurer to assist with my claim.

  • Position*
  • Date
     - -
    2 digit day, 2 digit month, 4 digit year
  •  
  • Should be Empty: