General Insurance Claim

General Insurance Claim Notification Form

Simply fill out the claim notification form below and one of our claims specialists will be in contact with you shortly.

Fields marked with an * are required

Please indicate if you are the broker or the policy holder? *

BrokerPolicy Holder

Broker First Name *

Broker Last Name *

Broker Email *

Insured Client Code (WinBEAT or Insight) *

Insured Details

First Name *

Last Name *

Email Address *

Phone *

Policy Number

Insured Person Name or Business Name

GST Registered?

YesNo

ABN

Input Tax Credit (ITC) Percentage?

Is the insured the preferred contact person? *

YesNo

Contact Details

Preferred contact person if not the insured details provided above.

First Name

Last Name

Email Address

Phone Number

Relationship to the insured

Claim Details

Date of Loss / Incident *

Loss Location

Third Party Name

Third Party Address

Description of claim *

Broker comments to claims staff

Additional Comments

Upload Supporting Documents or Files

File Upload 1

Browse

File Upload 2

Browse

File Upload 3

Browse

Do you have additional files to upload?

YesNo

File Upload 4

Browse

File Upload 5

Browse

File Upload 6

Browse

Signature

Draw signature|Type signatureClear

Save and Complete Later