Make An Unemployment Claim - Swann Insurance (Page 3 of 4) in pdf

declaration

I hereby declare that:

1. I am the person insured by Swann Insurance (Aust) Pty Ltd (Swann) and referred to in the foregoing particulars.

2. I agree that if I have made, or in any further declaration which Swann may require of me, shall make, any false declaration or statement in support of my

claim my right to any Benefit shall be forthwith forfeited.

3. I authorise the Centrelink/Job Agency or any person or firm who has employed me, to furnish to Swann any information it may request in respect of my

employment and unemployment.

4. To the best of my knowledge and belief the information in this form is true and correct and I have not withheld any relevant information.

5. I/we agree that, by submitting this form the personal information I/we provide to Swann in this form or otherwise may be collected, held, used and

disclosed in a manner set out in the Swann Privacy Policy found at , including for processing this claim.

SIGNATURE OF INSURED

SIGNATURE OF WITNESS

DATE

Swann Insurance is a member of the insurance industry’s Financial Ombudsman Service (Service). This independent Service is provided to the public at no cost and aims to resolve complaints

quickly and informally. However, you should bring your complaint to us first as in most cases, the complaint can be resolved easily. If you are dissatisfied with the outcome of our review, you may

then contact the Service for advice and assistance in resolving your complaint.

FINANCIAL OMBUDSMAN SERVICE TOLL FREE TELEPHONE NUMBER: 1300 780 808.

certificate of centrelink/job agency

IS THE CLAIMANT REGISTERED AS A JOBSEEKER?

YES

IF THE CLAIMANT IS RECEIVING JOB SEARCH ALLOWANCE/UNEMPLOYMENT BENEFITS, PLEASE COMPLETE THE FOLLOWING:

THIS IS TO CERTIFY THAT (FULL NAME)

OF (ADDRESS)

WAS REGISTERED AS BEING UNEMPLOYED ON (DATE)

ALLOWANCE/BENEFITS OF

PER

WERE GRANTED FROM (DATE)