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claim
form

 

Claim Form

Personal

your details

Policy number

First Name

Surname

Contact Phone Number

Street Address

Email

Postcode

Suburb

State

Country

Are you self employed?

Occupation

Are you entitled to claim back the GST component of costs relating to the insured property, as an Input Tax Credit from the ATO?

What is your ABN?

Other %

 

 

bank details

Bank name

Account number

BSB

Account name

 

 

bike details

Year

Make/Model

Bike type

Frame type

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Parties

interested parties

Does any other financial party hold an interest or encumbrance on the property claimed?

Financier

Is there another insurance policy covering the items claimed?

Insurer Name

Policy Number

Have you made a claim against this policy?

Claim Number

Incidents

incident details

Date of incident

Time

Type of Incident

Describe where the incident occurred

Were you participating in an organised sporting event

Other

Were you using the Bicycle for business purposes

Are you a Professional Athlete, Member of an Elite Training Squad or a Sponsored Athlete?

police report details

We cannot proceed with claims for theft or malicious damage without the following details:

Police report number

Date reported

Station

Have any charges been laid or any other Police action taken?

*Please keep us informed of any Police proceedings which may occur.

security details

What security arrangements did you have in place at the time of the incident?

What security improvements have been made since the loss?

Please advise in detail how the incident occurred. In the event of theft, please include how access to your property was gained

Describe the damage to your bike or other property

Items

 

list items claimed

Description of Property lost/damaged/stolen
Purchase Date
Retail Value
Is Item Repairable?
Amount Claimed
add another +
Total

Parties

other parties

Is another Party responsible for the incident ?

If another Party is at fault, why?

Responsible Parties Details:

Full Name

Contact No.

Email

Address

witness details

Are there any witnesses to the incident?

Finish

declaration

Thank you for submitting this claim request, we will process your information and deliver a response to you as soon as possible via email. Thank you for your patience.