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Property Claim Form

1. Policy Details

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GST Details:

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2. General Details Of Loss / Damage

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Was the lost/damaged property:

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If yes, please state):

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3. Complete This Section For Personal Valuables / Burglary / Theft:

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(If no, please state):

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4. Complete This Section For Fire / Damage To Premises

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5. Complete This Section For Transit Loss / Personal Baggage

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Note: Personal baggage claims must be accompanied by the original Policy document

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6. Statement Of Claim

Property/Articles lost, stolen, damaged or destroyed

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Declaration

I/We, the undersigned claimant(s) hereby declare that the foregoing statements and particulars of the claim are true and correct and that I/We have not withheld any information relevant to this claim. I expressly agree that the information given by me is provided with my full knowledge and consent and further agree to hold harmless and indemnify Action Insurance Brokers Pty Ltd, its Employees and Representatives in the event of any action or matter that may be taken by any party pursuant to the Privacy Act 1988 (Cth). I/We acknowledge that I/we have read and understood the paragraphs accompanying this proposal headed “Your Privacy”. In submitting this form, I acknowledge that I may receive documentation from Action Insurance Brokers P/L by email. I further agree that Action Insurance Brokers P/L may from time to time send me important information about new insurance products and services.

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