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CLAIM FORM
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LIABILITY CLAIM
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IN THE EVENT OF A CLAIM:
Take precautions necessary to ensure that no further loss or damage occurs to the property.
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This Claim Form should be completed and returned to your Broker as soon as possible with any relevant photos
and attachments.
Contact your Broker if you are unsure about any matters relating to completion of this Claim Form.
No repairs are to be commenced without the consent of Latitude Underwriting.
PLEASE NOTE:
Every question must be answered fully.
Incomplete, illegible or unclear answers will delay processing of your claim.
If insufficient space is provided, please attach separate sheet(s) and sign and date each sheet attached.
POLICY DETAILS:
INSURED:
POLICY NO.
ABN:
TO WHAT EXTENT CAN YOU CLAIM AN INPUT TAX CREDIT ON YOUR INSURANCE PREMIUMS?
%
ADDRESS:
CITY:
STATE:
POSTCODE:
CONTACT NAME:
TEL:
MOBILE:
FAX:
EMAIL:
INSURANCE BROKER:
NAME OF YOUR INSURANCE BROKER:
ADDRESS:
CITY:
STATE:
POSTCODE:
CONTACT NAME:
TEL:
MOBILE:
FAX:
EMAIL:
Level 13/141 Walker Street North Sydney NSW 2060 PO Box 1813 North Sydney NSW 2059
T: 02 9930 9580 F: 02 9930 9501 E: [email protected]
Latitude Underwriting P/L. A Corporate Authorised Representative of Austagencies P/L ABN 76 006 090 464 AFSL 244584
Version: July 2011
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THIRD PARTY DETAILS:
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FULL NAME:
ADDRESS:
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CITY:
STATE:
POSTCODE:
TEL:
MOBILE:
FAX:
EMAIL:
PARTICULARS OF ACCIDENT/INCIDENTS:
DAY OF INCIDENT:
DATE OF INCIDENT
/
/
TIME:
AM
PM
TIME:
AM
PM
LOCATION OF ACCIDENT/INCIDENT:
PLEASE DESCRIBE WHAT HAPPENED:
PLEASE PROVIDE DETAILS OF DAMAGED PROPERTY AND/OR INJURIES SUFFERED?
DATE REPORTED TO YOU
/
/
IF YOU HAVE ADMITTED RESPONSIBILITY IN ANY WAY, PLEASE GIVE DETAILS:
WERE EMERGENCY SERVICES SUCH AS AMBULANCE, POLICE OR FIRE BRIGADE CONTACTED?
YES
NO
IF “YES” PLEASE PROVIDE DETAILS:
Level 13/141 Walker Street North Sydney NSW 2060 PO Box 1813 North Sydney NSW 2059
T: 02 9930 9580 F: 02 9930 9501 E: [email protected]
Latitude Underwriting P/L. A Corporate Authorised Representative of Austagencies P/L ABN 76 006 090 464 AFSL 244584
Version: July 2011
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HOW REPORTED:
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REPORTED BY – NAME:
ADDRESS:
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CITY:
STATE:
TEL:
MOBILE:
FAX:
EMAIL:
HOW?
IN PERSON
POSTCODE:
BY TELEPHONE
BY LETTER
OTHER:
CAUSE:
PRODUCT
DOES THE CLAIM INVOLVE A PRODUCT THAT YOU MANUFACTURED/SUPPLIED TO ANOTHER PERSON?
YES
NO
DID THE ACCIDENT OR INJURY ARISE OUT OF THE USE OF A MOTOR VEHICLE?
YES
NO
WAS THE MOTOR VEHICLE REGISTERED OR REQUIRED TO BE REGISTERED?
YES
NO
YES
NO
YES
NO
IF “YES” PLEASE PROVIDE DETAILS:
MOTOR VEHICLE:
TYPE OF VEHICLE:
REGISTRATION NUMBER:
IF UNREGISTERED, WAS THE VEHICLE INSURED UNDER A MOTOR VEHICLE/OTHER INSURANCE POLICY?
DRIVERS NAME:
DRIVERS ADDRESS:
OWNERS NAME:
OWNERS ADDRESS:
PLANT & EQUIPMENT:
DID THE INCIDENT ARISE OUT OF THE USE OF PLANT OR EQUIPMENT?
DESCRIBE THE PLANT OR EQUIPMENT AND ITS USES:
Level 13/141 Walker Street North Sydney NSW 2060 PO Box 1813 North Sydney NSW 2059
T: 02 9930 9580 F: 02 9930 9501 E: [email protected]
Latitude Underwriting P/L. A Corporate Authorised Representative of Austagencies P/L ABN 76 006 090 464 AFSL 244584
Version: July 2011
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ANIMAL:
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DID THE INCIDENT ARISE OUT OF THE ACTIONS OF AN ANIMAL?
YES
PLEASE DESCRIBE TYPE OF ANIMAL:
NO
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DOES THIS ANIMAL BELONG TO YOU?
YES
NO
IS THE ANIMAL USUALLY CONFINED BEHIND FENCES?
YES
NO
HAS THE ANIMAL BEEN INVOLVED IN ANY INCIDENTS OF A SIMILAR NATURE?
YES
NO
YES
NO
IF NOT, PLEASE PROVIDE OWNERS NAME AND ADDRESS:
HOW LONG HAVE YOU OWNED THIS ANIMAL?
IF “YES” PLEASE PROVIDE DETAILS:
INDIVIDUAL:
WAS THE ACCIDENT DUE TO THE ACTIONS OF ANY INDIVIDUAL?
PLEASE PROVIDE THEIR NAME AND ADDRESS AND RELATIONSHIP TO YOU?
EG: MEMBER OF FAMILY, EMPLOYEE, SUB-CONTRACTOR, CLAIMANT)
NAME
ADDRESS
RELATIONSHIP
Level 13/141 Walker Street North Sydney NSW 2060 PO Box 1813 North Sydney NSW 2059
T: 02 9930 9580 F: 02 9930 9501 E: [email protected]
Latitude Underwriting P/L. A Corporate Authorised Representative of Austagencies P/L ABN 76 006 090 464 AFSL 244584
Version: July 2011
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PROPERTY:
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DESCRIPTION OF PROPERTY DAMAGED:
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NATURE AND EXTENT OF DAMAGE:
DO YOU OWN THE PROPERTY?
YES
NO
YES
NO
YES
NO
IF “NO” PLEASE ADVISE NAME AND ADDRESS OF OWNER:
DO YOU OCCUPY THE PROPERTY?
IF “NO” PLEASE ADVISE NAME OF TENANT AND DETAILS OF TENANCY:
WHAT CAUSED THE ACCIDENT (EG: BUILDING DEFECT, SPILT LIQUID ETC)
HAD ANY DEFECT OR HAZARD BEEN NOTIFIED TO YOU BY YOUR TENANT/AGENT?
IF “YES”, ADVISE DATE REPORTED
/
/
WHO REPORTED DEFECT OR HAZARD?
PLEASE DESCRIBE TYPE OF DEFECT/HAZARD REPORTED:
Level 13/141 Walker Street North Sydney NSW 2060 PO Box 1813 North Sydney NSW 2059
T: 02 9930 9580 F: 02 9930 9501 E: [email protected]
Latitude Underwriting P/L. A Corporate Authorised Representative of Austagencies P/L ABN 76 006 090 464 AFSL 244584
Version: July 2011
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WITNESSES:
NAME
ADDRESS
RELATIONSHIP
CONTACT NUMBER
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POLICE:
DID POLICE ATTEND THE ACCIDENT/INCIDENT?
DATE REPORTED:
/
/
YES
NO
CRIME REPORT NO.
IF “YES” NAME OF POLICE OFFICER:
NAME OF POLICE STATION:
DID POLICE LAY ANY CHARGES OR INTIMATE ACTION MAY BE TAKEN?
YES
NO
IF “YES”, PLEASE SUPPLY FULL DETAILS: (PLEASE ATTACH A COPY OF THE POLICE REPORT.)
DECLARATION AND AUTHORISATION:
The information and answers given above are true and complete in every detail.
I understand the claim may be refused or reduced if information is withheld.
I authorise that Latitude Underwriting give to and obtain from other insurers, insurance reference bureaus and credit
reporting agencies any information relating to the Insured’s credit or insurance history as well as insurance claims
information obtained during the course of this contract.
SIGNATURE OF INSURED:
DATE:
NAME: (PLEASE PRINT)
WITNESS:
DATE:
NAME: (PLEASE PRINT)
Please note: If the insured is a company, partnership or other business venture, this declaration must be made
and signed by an authorised person.
Level 13/141 Walker Street North Sydney NSW 2060 PO Box 1813 North Sydney NSW 2059
T: 02 9930 9580 F: 02 9930 9501 E: [email protected]
Latitude Underwriting P/L. A Corporate Authorised Representative of Austagencies P/L ABN 76 006 090 464 AFSL 244584
Version: July 2011
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AGENT OF THE INSURERS
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In accordance with the requirements of the Corporations Act 2001 Austagencies Pty Ltd in arranging or effecting
this insurance, or dealing with or settling claims will be acting under an authority given to it by certain Insurers.
Accordingly Austagencies Pty Ltd will be acting as an agent of the insurers and not an agent of the insured.
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PRIVACY:
Privacy legislation regulates the way private sector organisations can collect, use, keep secure and disclose
personal information. Austagencies Pty Ltd has developed a Privacy Policy, which explains what sort of personal
information we hold about You and what we do with that information.
To obtain a copy of Austagencies Pty Ltd Privacy Policy, please contact Your Financial Services Provider or visit
our website at www.austagencies.com.au.
Level 13/141 Walker Street North Sydney NSW 2060 PO Box 1813 North Sydney NSW 2059
T: 02 9930 9580 F: 02 9930 9501 E: [email protected]
Latitude Underwriting P/L. A Corporate Authorised Representative of Austagencies P/L ABN 76 006 090 464 AFSL 244584
Version: July 2011
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