INSURANCE CLAIM FORM

Confidential

1. POLICY DETAILS

Insurance Company Name: [NAME OF INSURER]

Policy Number: [POLICY NUMBER]

Policy Type: [e.g. Public Liability / Tool Insurance / Property]

Claim Number: [LEAVE BLANK - FOR INSURER USE]

Date of Issue: [DATE POLICY STARTED]

2. INSURED DETAILS

Business Name: [REGISTERED BUSINESS NAME]

ABN: [AUSTRALIAN BUSINESS NUMBER]

Contact Name: [PRIMARY CONTACT PERSON]

Phone Number: [MOBILE OR LANDLINE]

Email Address: [EMAIL ADDRESS]

Business Address: [STREET ADDRESS] [SUBURB] [STATE] [POSTCODE]

Mailing Address (if different): [POSTAL ADDRESS] [SUBURB] [STATE] [POSTCODE]

3. INCIDENT DETAILS

Date of Incident: [DD/MM/YYYY]

Time of Incident: [HH:MM AM/PM]

Location of Incident: [FULL ADDRESS OR SITE NAME]

Description of Incident: [PROVIDE A DETAILED DESCRIPTION. DESCRIBE WHAT HAPPENED, WHO WAS INVOLVED, AND THE IMMEDIATE AFTERMATH. DO NOT ADMIT FAULT. USE FACTUAL LANGUAGE.]

4. TYPE OF LOSS OR DAMAGE

Please select the type of claim:

[ ] Property Damage [ ] Bodily Injury [ ] Theft / Burglary [ ] Professional Indemnity [ ] Product Liability [ ] Other: [SPECIFY]

Description of Damage or Injury: [DESCRIBE THE EXTENT OF DAMAGE TO PROPERTY OR THE NATURE OF THE INJURY]

5. WITNESS INFORMATION

Were there any witnesses? [YES / NO]

Witness 1 Name: [FULL NAME] Address: [ADDRESS] Phone: [PHONE NUMBER]

Witness 2 Name: [FULL NAME] Address: [ADDRESS] Phone: [PHONE NUMBER]

6. THIRD PARTY DETAILS

(If applicable)

Third Party Name: [NAME OF PERSON OR BUSINESS AFFECTED]

Contact Person: [NAME OF CONTACT]

Phone Number: [PHONE NUMBER]

Address: [ADDRESS]

Nature of Claim against Third Party: [DESCRIBE WHY THE THIRD PARTY IS MAKING A CLAIM AGAINST YOU OR WHY YOU ARE MAKING A CLAIM AGAINST THEM]

7. AUTHORITIES NOTIFIED

Police Reported? [YES / NO]

Police Station: [NAME OF STATION]

Event Number: [POLICE REFERENCE NUMBER]

WHS Authority Notified? [YES / NO]

Reference Number: [WHS REFERENCE NUMBER]

8. FINANCIAL DETAILS

Estimated Cost of Loss: $[0.00]

Breakdown of Costs:

• [ITEM 1] $[0.00]
• [ITEM 2] $[0.00]
• [ITEM 3] $[0.00]

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: __________________________

Name: [PRINT NAME]

Date: [DD/MM/YYYY]

10. ATTACHMENTS

[ ] Photos of damage [ ] Police Report [ ] Quotes for repairs [ ] Medical Certificates [ ] Witness Statements [ ] Invoices / Receipts