Property Claim Form

Property 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.
Brokerage
Broker Email
If unknown, use info@repx.au
Claim Number (if known)
1. Policy Details
Name of Policy Holder
Please provide your registered company name if applicable
Address of Policy Holder

Street Address

Street Address Line 2

City

Postal / Zip Code
Policy Number
Insurer
Expiry Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Contact Details
First Name
Last Name
Email
example@example.com
Phone Number

Area or Mobile CodePhone Number

5. Item / Property Loss Schedule
Please complete for loss/theft of property:
Please complete for damage of property:
Upload relevant invoice/quotes from repairer

Cancelof
6. ABN Details
Are you a registered business?
What is your ABN?
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?
%

Declaration
I, {firstName176} {lastName177}, 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.
First Name
Last Name
Position
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Hour MinutesAM/PM Option
Signature
Should be Empty:

1. Policy Details