General Insurance Claim Page 2
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1
2Details of repair work and/or replacement:
Repair work or replacement has been carried out.
(If repair/replacement has been carried out, please attach invoice, alternatively attach quotation for repair/replacement)
List item lost, stolen
Owner
If known:
Purchase
Input tax credit you
Amount
or
of item
Date, name
price
can claim on the
claimed
damaged
& address of
$
purchase of these
$
company where
items as a % of the
item purchased.
total GST payable.
Less Excess of : $
Total $
Electronic Funds Transfer Details
Following insurers approval of your claim, should you wish to have your funds transferred directly into your bank account, please
provide the following details.
Name of Financial Institution:
Account name:
¨¨¨
¨¨¨
¨¨¨¨¨¨¨¨¨
BSB:
-
Account Number:
Important Notice
I hereby declare the above statements and particulars to be true and correct and I make this declaration on the basis that I have
delegation of power to sign for and on the behalf of the Insured.
Date:
/
/
Signature of insured or person with authority to sign on behalf of the insured.
EngInsure
Insurance + Risk Services
Level 5, 90 Collins Street, Melbourne VIC 3000
P 1300 854 251
Licensee: Whitbread Associates Pty Ltd trading as EngInsure Insurance & Risk Services
E .au
ABN: 69 005 490 228 Licence No. 229 092
W .au
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