General Insurance Claim Form

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General Insurance Claim

Policy Number
Due Date
Date Format: MM slash DD slash YYYY
Full Name
Email
Address
Business Phone
Private Phone
Fax No.
Occupation/Business/Industry/Trade
What is your Australian Business Number (ABN)?
Name any other interested party
Capacity
Address
Is there any other Insurance in force which would cover this in whole or part
- Yes
- No
If Yes, please advise in the space provided.
Insurer’s Name
Policy Details
Are you registered for GST?
- Yes
- No
To what extent are you registered to claim an Input Tax Credit on the GST applicable to the premium?*
Description of loss or damage
To assist in assessing the loss, the following information is requested.
Description 1
Date of Loss
Time
Description
Sum Claimed $
Date of purchase
From whom purchased
Purchase Price $
Replacement Value $
*Input Tax Credit %
*Please show the Input Tax Credit you are entitled to claim on the purchase of each item as a percentage of the total GST payable.
Description 2
Date of Loss
Time
Description
Sum Claimed $
Date of Purchase
From whom purchased
Purchase Price $
Replacement Value $
*Input Tax Credit %
*Please show the Input Tax Credit you are entitled to claim on the purchase of each item as a percentage of the total GST payable.
Description 3
Date of Loss
Time
Description
Sum Claimed $
Date of Purchase
From whom purchased
Purchase Price $
Replacement Value $
*Input Tax Credit %
*Please show the Input Tax Credit you are entitled to claim on the purchase of each item as a percentage of the total GST payable.
Total amount claimed $
Details of Loss Damage or Occurrence
Date of Loss / Damage / Occurrence
Time
When was it reported to you? (If applicable)
Time
Place and/or premises where it occurred
Please state full details of how loss/damage/accident occurred
Please describe nature of damage or injury
When were the Police notified? (If applicable)
Time
Police Station
Officers name
Police Report No.
Responsibility/Witnesses
In your opinion was any other person(s) responsible for loss or damage Or cause of the Occurrence?
- Yes
- No
Full Name
Address
Business Phone
Private Phone
Fax No.
Reasons
Was there a witness or witnesses to this event?
- Yes
- No
If YES, please give full details.
Name of Witnesses
Witnesses’ Address
Business Phone
Private Phone
Fax No.
Insurance History
Have you ever previously sustained loss/damage or caused damage or injury to 3rd parties
- Yes
- No
If YES, give details of such losses and amounts involved.
Was an Insurance Company involved?
- Yes
- No
If YES, please state name of company and year of claim.
Have you been convicted of or had any fines or penalties imposed for any criminal offences in the last 10 years?
- Yes
- No
If YES, please provide details.
Please type your name below to agree to our terms
Email
This field is for validation purposes and should be left unchanged.

Risk Insure Pty Ltd

86 Pirie Street
Adelaide
SA 5000
Australia

Email for General Enquiries: info@riskinsure.com.au

For all Phone Insure Enquiries: 1300 303 772

Risk Insure Pty Ltd

ABN 23 090 918 399
AFSL 230163

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General Insurance Claim

Description of loss or damage

Details of Loss Damage or Occurrence

Responsibility/Witnesses

Insurance History

Risk Insure Pty Ltd