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?*YesNoHave you claimed or intend to claim an input tax credit on the GST component of the premium applicable to the Policy?*YesNoWill you be claiming an amount less than 100%?YesNoSpecify the percent amount claimedAre you entitled to claim an input tax credit for repairs or replacement of the item that has been lost or damaged?*YesNoIf yes, will you be claiming an amount less than 100%?YesNoSpecify the percent amount claimed Business DetailsNature of Business*Address* Street Address Address Line 2 City State Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Contact DetailsBusiness*PrivateFacsimileMobile The PropertyAre you the owner of the propery being claimed for?*YesNoIf no, please give detailsWas there any other insurance covering this damage current at the time of occurrence?*YesNoName of InsurerPolicy NumberDoes any other party have an interest in the damaged property the subject of the claim?*(eg. Mortgagee, Finance Co. leasee)YesNoNamePhone The Premises Where did the loss occur?Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Describe the premises.*Ie, Factory, Warehouse, Office Block etc.Are the premises tenanted?*YesNoIf yes, give details of tenant.Are you the tenant?YesNoGive details of building ownerWere the premises occupied at the time of the loss?*YesNo, give details of when last occupied.Name First Last HourDayDate Incident DetailsDay of Incident*Date of Incident* Between the hours of* : HH MM AM PM and* : HH MM AM PM How did the damage/loss occur?*Was another person responsible for the damage?*YesNoNameGive name and address of person responsible. First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Details of Previous Loss Or DamageHave you suffered any loss, damage or theft at this address or elsewhere in the last 5 years?YesNoPlease give details of up to the last 5 incidents.TypeDate (dd/mm/yyyy)Amount ($) Have you made a claim on any insurer for any of the above mentioned incidents?YesNoPlease give details belowInsurerDate (dd/mm/yyyy)Amount ($) 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?*YesNoWhat was broken?Was the break through the entire thickness of the material?YesNoHas the break been repaired?YesNoIf yes, have you paid the account?YesNoWas there damage to window sign-writing?YesNoPlease attach invoice or quotation.Accepted file types: pdf, png, jpg. Storm and Water DamageAre you claiming storm and water damage?*YesNoDescribe the damageHow did the Wind, Rain or Water enter the premises?Did the storm cause this opening?YesNoIf yes, give details Theft or BurglaryAre you claiming theft or burglary?*YesNoAttach 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 Accepted file types: pdf, jpg, png. 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?YesNoIf 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.Did the device activate as a result of theft?YesNoN/A Police DetailsHave the police been notified?YesNoName (who notified the police) Full Name PhonePolice StationDate notified Crime Report No.Please attach a copy of the Police Report, if availableAccepted file types: pdf, jpg, png.If the damage is the result of fire, did the fire brigade attend?YesNo 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)Are you claiming damage to buildings?*YesNoDamage BuildingParticularsName of RepairerAmount Claimed ($) Are you claiming loss or damage to other property?*YesNoLoss or Damage to Other PropertyDescription of Property (including serial number)Where PurchasedWhen Purchased (dd/mm/yy)Value at Time of Loss ($)Replacement Value ($) Attach quotes herePlease combine and attach all quotes as a single file here.Accepted file types: pdf, jpg, png.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* Name of Insured Person 2Electronic signature for the declaration above. First Last SignatureDate 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. YesNoNameThis field is for validation purposes and should be left unchanged.