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

Make An Unemployment Claim - Swann Insurance Page 4

Third Person Authority to make and receive claims enquiries in

relation to my claim

If you wish to provide authority for another person to discuss your claim on your behalf,

please complete the following authorisation and return with your completed claim form.

I , __________________________________________________________ (name) of

____________________________________________________________ (address),

freely give permission for:

Name:

_____________________________________________________

Address:

_____________________________________________________

Contact Ph. No.:

_____________________________________________________

to contact and be contacted by Swann Insurance (Aust) Pty Ltd to discuss information

relating to and about my disablement claim, (number ____________________).

I know that I may request a copy of this authorisation. I agree that a copy of this

authorisation shall be as valid as the original.

I understand that this authorisation shall be valid until my claim is processed and

finalised, and that I have a right to revoke this authorisation by written notification to

Swann Insurance.

Signed by …………………………………………………………………………………………

Print name ………………………………………………………………………………………...

Dated ………………………………………………………………………………………………

Witness signature ……………………..………………………….………….…………………..

Print name ……………………………………………………………..…….…………………...

Dated ………………………………………………………………………………………………

Swann Insurance (Aust) Pty Ltd ABN 80 000 886 680

Locked Bag 3274 Melbourne VIC 3001 t 1300 657 382 f 1300 657 370 e .au

G2427-0810 PRN_D375

Make An Unemployment Claim - Swann Insurance Page 4