Step 1 of 14 7% Business Claim Form The issue of this form does not constitute an admission of liability on the part of the insurer. Save and Continue: If you need to, you may save and continue completing this form at a later time. Click the 'save and continue later' link at the bottom of any page to do so. NOTE: Do NOT use the back button in your browser, use the PREVIOUS/NEXT buttons at the bottom of each page to go back and forward. Important: Please complete PART A - Compulsory for all claims. PART B - Relevant sections pertaining to your claim. PART C - Compulsory for all claims. PART A - Compulsory for all claims.The InsuredBusiness Name* What is your ABN?* Are you registered for GST?* Yes No Have you claimed or intend to claim an input tax credit on the GST component of the premium applicable to the Policy?* Yes No Will you be claiming an amount less than 100%? Yes No Specify the percent amount claimed Are you entitled to claim an input tax credit for repairs or replacement of the item that has been lost or damaged?* Yes No If yes, will you be claiming an amount less than 100%? Yes No Specify the percent amount claimed Business DetailsNature of Business* Address* Street Address Address Line 2 City State Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Contact DetailsBusiness*PrivateFacsimileMobile The PropertyAre you the owner of the propery being claimed for?* Yes No If no, please give detailsWas there any other insurance covering this damage current at the time of occurrence?* Yes No Name of Insurer Policy Number Does any other party have an interest in the damaged property the subject of the claim?*(eg. Mortgagee, Finance Co. leasee) Yes No Name Phone The Premises Where did the loss occur?Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Describe the premises.*Ie, Factory, Warehouse, Office Block etc. Are the premises tenanted?* Yes No If yes, give details of tenant. Are you the tenant? Yes No Give details of building owner Were the premises occupied at the time of the loss?* Yes No, give details of when last occupied. Name First Last HourDay Date MM slash DD slash YYYY Incident DetailsDay of Incident* Date of Incident* MM slash DD slash YYYY Between the hours of* : Hours Minutes AM PM and* : Hours Minutes AM PM How did the damage/loss occur?*Was another person responsible for the damage?* Yes No NameGive name and address of person responsible. First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Details of Previous Loss Or DamageHave you suffered any loss, damage or theft at this address or elsewhere in the last 5 years? Yes No Please give details of up to the last 5 incidents.TypeDate (dd/mm/yyyy)Amount ($) Have you made a claim on any insurer for any of the above mentioned incidents? Yes No Please give details belowInsurerDate (dd/mm/yyyy)Amount ($) PART B - Complete relevant sections pertaining to your claim.If any of the following sections are not relevant, you may skip and continue. Click on NEXT below to continue. Breakage of GlassAre you claiming breakage of glass?* Yes No What was broken?Was the break through the entire thickness of the material? Yes No Has the break been repaired? Yes No If yes, have you paid the account? Yes No Was there damage to window sign-writing? Yes No Please attach invoice or quotation.Accepted file types: pdf, png, jpg, Max. file size: 64 MB. Storm and Water DamageAre you claiming storm and water damage?* Yes No Describe the damageHow did the Wind, Rain or Water enter the premises?Did the storm cause this opening? Yes No If yes, give details Theft or BurglaryAre you claiming theft or burglary?* Yes No Attach files here.Please attach original purchase dockets, invoices or receipts. If you provide as much proof about owning the items it will help us to process your claim quickly. Drop files here or Select files Accepted file types: pdf, jpg, png, Max. file size: 4 MB, Max. files: 5. How were the premises entered and where was the point of entry?Which parts of the premises were entered?Have the police recovered any property? Yes No If yes, give details Security Details Any loss involving malicious damage, lost or stolen property must be notified to the policeAre any of these used to provide security to the premises?Check all that apply. Keyed window locks on all accessible windows Double keyed deadlocks on all perimeter doors Back to base (please attach activity report below) Grilles on all accessible windows and doors Perimeter Alarm Internal Alarm Fixed Safe Free standing safe None Attach activity report here.Accepted file types: jpg, png, pdf, Max. file size: 4 MB.Did the device activate as a result of theft? Yes No N/A Police DetailsHave the police been notified? Yes No Name (who notified the police) Full Name PhonePolice Station Date notified MM slash DD slash YYYY Crime Report No. Please attach a copy of the Police Report, if availableAccepted file types: pdf, jpg, png, Max. file size: 16 MB.If the damage is the result of fire, did the fire brigade attend? Yes No PART C - Compulsory completion for all claims.Details of Claims Please note both sections below maximum 15 items. If you need to claim more, please attach a list and show total amounts only below. Attach list here if insufficient space below (more than 15 items)Max. file size: 64 MB.Are you claiming damage to buildings?* Yes No Damage BuildingParticularsName of RepairerAmount Claimed ($) Are you claiming loss or damage to other property?* Yes No Loss or Damage to Other PropertyDescription of Property (including serial number)Where PurchasedWhen Purchased (dd/mm/yy)Value at Time of Loss ($)Replacement Value ($) Attach quotes herePlease combine and attach all quotes as a single file here.Accepted file types: pdf, jpg, png, Max. file size: 8 MB.We are not responsible for payment of invoices, however, please indicate if you request payment to any other party. Declaration and AuthorisationThe information and answers given above are true and complete in every detail. I understand the claim may be refused or reduced if information is withheld. Name of Insured Person 1*Electronic signature for the declaration above. First Last Signature*Date* MM slash DD slash YYYY Name of Insured Person 2Electronic signature for the declaration above. First Last SignatureDate MM slash DD slash YYYY Note: Before submitting this form, please check that it has been fully completed as any omissions may delay your claim. I have checked the form to ensure it is correct.*Please answer Yes here, to be able to submit your claim. Yes No CommentsThis field is for validation purposes and should be left unchanged.