Insurance Claim Form Example
Example document for Insurance Claim Form. Use this as a reference when creating your own.
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Document: Insurance Claim Form
Example Document
Last updated 7/30/2026
INSURANCE CLAIM FORM
Confidential
1. POLICY DETAILS
Insurance Company Name: All Trades Insurance Ltd
Policy Number: ATL-99887766
Policy Type: Public Liability
Claim Number: [LEAVE BLANK]
Date of Issue: 01/07/2023
2. INSURED DETAILS
Business Name: Smith's Bricklaying Services
ABN: 12 345 678 901
Contact Name: John Smith
Phone Number: 0400 123 456
Email Address: john@smithbricklaying.com.au
Business Address: 12 Builder Lane
Melbourne
VIC 3000
Mailing Address: Same as above
3. INCIDENT DETAILS
Date of Incident: 15/10/2023
Time of Incident: 2:30 PM
Location of Incident: 45 Ocean View Road, Sandringham VIC 3191
Description of Incident: While laying bricks in the driveway, a stack of timber pallets left by the delivery driver tipped over. The pallets struck the client's fence, breaking three wooden posts and damaging the adjacent brickwork. The work area was cordoned off with safety tape. No one was injured.
4. TYPE OF LOSS OR DAMAGE
Please select the type of claim:
[X] Property Damage [ ] Bodily Injury [ ] Theft / Burglary [ ] Professional Indemnity [ ] Product Liability [ ] Other:
Description of Damage or Injury: Three fence posts snapped at ground level. Approximately 10 square metres of brick fence cap damaged.
5. WITNESS INFORMATION
Were there any witnesses? [YES / NO]
Witness 1 Name: Sarah Jones (Homeowner) Address: 45 Ocean View Road, Sandringham Phone: 0411 222 333
6. THIRD PARTY DETAILS
(If applicable)
Third Party Name: Sarah Jones
Contact Person: Sarah Jones
Phone Number: 0411 222 333
Address: 45 Ocean View Road, Sandringham
Nature of Claim against Third Party: The client has submitted a request for repair of the fence damage.
7. AUTHORITIES NOTIFIED
Police Reported? [YES / NO]
Police Station:
Event Number:
WHS Authority Notified? [YES / NO]
Reference Number:
8. FINANCIAL DETAILS
Estimated Cost of Loss: $2,500.00
Breakdown of Costs:
- Fence Contractor Quote $2,200.00
- Waste Removal $300.00
9. DECLARATION
I declare that the information provided in this form is true and correct to the best of my knowledge. I understand that making a false statement may result in the rejection of my claim and potential legal action. I authorize the insurer to obtain any information necessary to assess this claim.
Signature: J Smith
Name: John Smith
Date: 16/10/2023
10. ATTACHMENTS
[X] Photos of damage [ ] Police Report [X] Quotes for repairs [ ] Medical Certificates [ ] Witness Statements [ ] Invoices / Receipts
Notes
Annotations:
- Policy Details: Accurate policy number is for the insurer to locate the file.
- Description of Incident: The description is factual and chronological. It does not blame the delivery driver or admit negligence. It simply states the physical mechanics of the event.
- Type of Loss: Property damage is selected because only the fence was broken.
- Witness Details: The homeowner is listed as the primary witness and the affected third party.
- Financial Details: Includes a specific quote from a contractor rather than a guess. This speeds up the assessment process.
About this Example
Part of the Insurance Claim Form document collection
Document Type
Insurance Claim Form
A formal request to an insurance company asking for payment based on the terms of an insurance policy. This document is essential for tradespeople and businesses to recover costs from accidents, theft, or liability.