Policy Number:Due Date:Insured DetailsName of insured*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email* OccupationDate of Birth Date Format: MM slash DD slash YYYY Mobile Phone*Business Phone*Time : HH MM AM PM What is your Australian Business Number (ABN)?Are you registered for GST?YesNoTo what extent are you entitled to claim an Input Tax Credit on the GST applicable to the premium?*Where did the loss occur?Date of loss Date Format: MM slash DD slash YYYY Describe as fully as possible how loss occurredDo you consider any other party responsible for the loss?YesNoIf YES, Please state why.Are you the sole owner of the property lost or damagedYesNoIf NO, give details of other owners or part owners.Do you hold any other insurances under which a claim for this loss may be lodged?YesNoIf YES, please give details.Name and type of appliance to which motor is attachedWho was it purchased from?Date of purchase Date Format: MM slash DD slash YYYY PriceIs the motor under manufactures warranty?YesNoIf YES, has a claim been made under the warranty?Electrical Repairers ReportMake of MotorHpSerial No.VoltageRMPOpen or sealedAgeDetails of DamageCause of DamagePlease attach actual repair accountRepair Costs Windings$Compressor$Other Repairs$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 of GoodsQuantityCostAmount Claimed*Input Tax Credit % Repairs having been completed to my satisfaction I hereby claim the amount ofName First Last Date Date Format: MM slash DD slash YYYY How would you prefer us to contact you?* Phone Email How To Get Quick Action On Your Claim 1. Complete this form and submit. If an assessor is appointed, directly email completed forms. 2. Attach all original quotations or invoices obtained for replacement of repair to the damaged or missing property. Photocopies are not accepted as a rule. 3. Attach original valuations and receipt of purchases if possible. 4. Advise the Police immediately in the event of loss by burglary, housebreaking, theft, suspected malicious damage. Also make sure the premises are secure to avoid further incidents. 5. Attach any letter of demand or other correspondence that you may receive from any Third Party. 6. Do not make any admission of liability for loss or damage caused by you to the Third Parties.Attach Files Drop files here or Note: Police reports are very slow so if you can obtain one at the time the report is taken, then this will save valuable time or at least obtain a copy or report number.What we will do if paperwork is correct and complete: 1. Submit the claim form to the Insurer. 2. An assessor is an independent person who is appointed by the Insurer for the expertise in helping you finalise a larger or more difficult claim. 3. If the claim has not been paid within 30 days we will contact the Insurer and then advise you accordingly. 4. We will then follow up the claim when necessary until settlement is reached, however, please feel free to call at any time.What an assessor will do:They will interview and obtain details of a loss and arrange for quotes and prepare the necessary paperwork. The assessor is your point of contact. The assessor will write a report to the Insurer recommending a course of action. This can take some time depending on their workload and Police reports. The Insurer will not act until these reports are received and although not bound by the assessor recommendations, the Insurers usually accept these reports. If you are unhappy with any aspect of the claim, advise the assessor. If they are unable to correct the problem, then contact us immediately. We will not know of any problem without being advised. If you are unhappy with the assessor’s responses, contact us immediately.