Make An Unemployment Claim - Swann Insurance Page 2
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4INVOLUNTARY UNEMPLOYMENT CLAIM FORM
Insurer: Swann Insurance (Aust) Pty Ltd ABN 80 000 886 680.
All questions must be answered.
Please print and indicate 3 where applicable. If there is insufficient space, please write on a separate sheet and attach to this form.
IMPORTANT NOTE
Please ensure that you have answered all questions relating to yourself and arrange for Centrelink/Job Agency Certificate
and Employers Declaration to be completed. Please note that an incomplete claim form will cause delay in assessment.
Please forward your completed claim form to Swann Insurance within 14 days of the occurrence.
Please notify Swann Insurance when you recommence employment.
your personal details
TITLE (e.g. MR/MRS)
SURNAME
GIVEN NAMES
DATE OF BIRTH
/
/
ADDRESS
POSTCODE
E-MAIL
TELEPHONE NO.
(
)
NAME AND DATE OF BIRTH OF ANY OTHER PERSON LISTED ON POLICY
claimant’s statement
NAME OF LAST EMPLOYER
ADDRESS
POSTCODE
TELEPHONE NO.
OCCUPATION
DATE EMPLOYED
(
)
FROM
/
/
/
/
TO
ON WHAT BASIS WERE YOU EMPLOYED AT POLICY COMMENCEMENT DATE?
FULL TIME
CASUAL
PART TIME
CONTRACT
SEASONAL
TEMPORARY
WHAT WAS YOUR REASON FOR LEAVING THIS EMPLOYMENT?
RESIGNED
RETRENCHED
DISMISSED
END OF CONTRACT
MADE REDUNDANT
TEMPORARY
OTHER
PLEASE GIVE EXPLANATION
NAME OF EMPLOYER PRIOR TO LAST EMPLOYMENT
ADDRESS
POSTCODE
TELEPHONE NO.
OCCUPATION
DATE EMPLOYED
/
/
/
/
(
)
FROM
TO
ON WHAT BASIS WERE YOU EMPLOYED AT POLICY COMMENCEMENT DATE?
FULL TIME
CASUAL
PART TIME
CONTRACT
SEASONAL
TEMPORARY
WHAT WAS YOUR REASON FOR LEAVING THIS EMPLOYMENT?
RESIGNED
RETRENCHED
DISMISSED
END OF CONTRACT
MADE REDUNDANT
TEMPORARY
PLEASE GIVE EXPLANATION
OTHER
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