Allianz General Claim Form
- 1. Property Claim Form Property Personal and Commercial The supply or acceptance of this form is not an admission of liability on the part of Allianz. Claim Number Name of Insured: Occupation Contact Person Home Phone No. Work Phone No. Mobile No. Email Occupation Postal Address Postcode Broker/Agent Name Phone No. Policy No. Excess $ Inception Date Expiry Date Interested Parties: Is the property being claimed for under a Financial Agreement? Yes ■ No ■ Name of Financier Contract No. G.S.T.: Are you registered for GST purposes? Yes ■ No ■ A.B.N. To what extent are you entitled to claim an Input Tax Credit on the GST for this policy? % Incident Description: What happened, how (eg. if burglary, include how entry was gained and details of forced entry) and the name of any party who caused damage etc? Date of Loss Time of Loss Type of Loss Address Where Loss Occurred Postcode Date premises last occupied Name of last occupier Schedule (if insufficient space, provide separate list): * Please show the extent to which an ITC can be claimed by you on each item * All original repair invoices, quotes or receipts must be submitted to avoid any delays in processing * Show all values in Australian Dollars Description of property lost/damaged/stolen (include names of owners of items if not owned by Year Where Replacement or Amount ITC%* the insured) Purchased Purchased Repair Cost Claimed Entitlement $ $ $ $ $ $ $ $ $ $ Total Claimed $ (If insufficient space, attach list). CLM001 01/04 Allianz Australia Insurance Limited AFS Licence No. 234708 ABN 15 000 122 850 Registered Office: 2 Market Street Sydney NSW 2000
- 2. Police: Have the Police been notified? (All Burglary/Theft/Malicious Damage claims must be reported) Yes ■ No ■ Police Station Reporting Officer Police report No. Date reported Security: Give details of any extra precautions or security improvements taken since the loss Give details of any other action taken to recover or reduce your loss Third Parties: Do you know who was responsible for the damage? Yes ■ No ■ Name Phone No. Address Postcode Other details (eg registration no.) Witnesses: Were there any witnesses to the Event? Yes ■ No ■ (If yes, please complete the following) Name Phone No. Postal Address Postcode Where was the Witness? Other Insurance: Is there any other Insurance on the property? (consider Travel, Medical Insurances also) Yes ■ No ■ Name of Insurer Policy details History: Have you had any insurance or renewal of insurance declined or cancelled or special conditions imposed in the last 5 years? Yes ■ No ■ Have you ever been convicted of or had any fines or penalties imposed for any criminal offence? Yes ■ No ■ Have you suffered a loss or made a claim on a property related insurance policy in the last 5 years? Yes ■ No ■ If yes to any history questions please give details Privacy: The Privacy Act 1988 requires us to tell you that external claims data collectors, investigators and agents as an insurer we collect your personal and sensitive or other parties as required by law. information in order to calculate your loss and You have the right to seek access to your personal entitlements, determine our liability, compile data and information and to correct it at any time. Please contact handle claims. When handling claims, we may have to us on 1300 360 529 EST 9am-5pm, Monday-Friday and disclose your personal and other information to third advise us of the changes. parties such as other insurers, reinsurers, loss adjusters, IDR Statement: Disputes are not an everyday If you are not satisfied with the outcome of this process, occurrence at Allianz. However we do provide an we will advise you how to contact the insurance internal dispute resolution process should any dispute industry’s external independent complaints scheme arise. Please feel free to ask for details. (subject to eligibility). Declaration: I/We certify that the information given in consent to the collection, storage, use and disclosure of this form is truthful, accurate and complete. No personal and sensitive information of all persons information likely to affect this claim has been withheld. affected by this claim, with their approval. I/We I/We understand that this claim may be refused if acknowledge that if I/we do not agree to the collection information is untrue, inaccurate or concealed. of this personal and sensitive information then Allianz I/We acknowledge that I/we have read and understood will be unable to process my/our claim. the Privacy Act 1988 information referred to above and Signature of Insured Date