Please answer all questions. This will help us process your claim quickly.
If you need more space to answer any of the questions, please use a separate sheet of paper.
Any attachments will form part of this claim report and the declaration will include them.
Policy Number 15T4149339
P&C President, Secretary or Treasurer Details
Details Of Incident
If theft occurred the Police must be notified, please provide the following details:
Equipment/Appliance Damage Details
Please supply as much details as possible to assist in processing the claim.
If yes, please indicate when and provide description.
Summary of Losses (if more than 3 items please attached)
Who reported the incident to you?
Please identify any witnesses
This policy does not provide cover in relation to events that occurred before the contract was
An excess is applicable when we pay you for your claim, see the policy for details.
The Company will, at its option:
Reinstate or repair the property or any part thereof; or
Pay the cost of such reinstatement or repair subject to due allowance for wear, tear, depreciation or
betterment, but the Company will not be liable to make any payment until the cost of reinstatement
or repair is actually incurred; or
Pay the insured the value of the property at the time of the destruction, loss or damage.
If you fail to comply with your duty of disclosure the insurer may be entitled to reduce its liability
under the contract in respect of the claim, or may cancel the contract.
If your non-disclosure is fraudulent, the insurer may also have the option of avoiding the contract
from its beginning.
I declare that the property claimed for has been lost, destroyed or damaged in the manner described
and belief the information in this form is true and correct and I have not withheld any relevant
I consent to the Insurance Underwriter using my personal information I have provided on this form
for the purpose of processing this claim. I understand that if I choose not to provide the required
details, this is my choice, however, the Insurance Underwriter may not be able to process the claim.
I consent to the Insurance Underwriter disclosing my personal information to other insurers, an
insurance reference service or as required by law. I consent to the Insurance Underwriter also
disclosing my personal information to and/or collecting additional information about me from
investigators or legal advisors.