Musical Instrument Claim Form

Insured

Policy Number

Address

Street address

City

State

Postcode

Are you registered for GST?

YesNo

ABN

ITC Proportion (%)

Contact Number

Occupation

Are there any other Insurance's in force that would cover this in whole or in part?

YesNo

Please provide Insurer and policy details

Are you the sole occupier of the premises where the loss occurred?

YesNo

Please provide details

Are you the owner of the property for which this claim is being made?

YesNo

Please provide details

Details of Loss or Damage

Please state the date of damage

Time

AM/PM

When was the loss/damage/occurrence first noticed and reported to you?

Time

AM/PM

Place and/or premises where it occurred

Please state fully how the loss, damage or accident occurred

Please describe the nature of damage or loss

Responsibility / Witness

Was another person, in your opinion responsible for the loss or damage or cause of the occurrence?

YesNo

Please provide details

Was there a witness or witnesses to this event?

YesNo

Please provide details

Insurance History

Have you previously sustained loss or damage or cause damage or injury to third parties?

YesNo

Please provide details (including if an insurer was involved and policy details)

Description of Property Lost or Damaged

Item Description

Purchased

Supplier

Purchase Price ($)

Amount Claimed ($)

Burglary Theft or Malicious Damage

Are you claiming for Burglary, Theft, or Malicious Damage?

YesNo

Please provide full details of method of entry

Were the police notified?

YesNo

Police Station

When were they notified?

Officer

Report Number

Why was it not reported to police?

Electronic Funds Transfer (EFT) Details

Do you want the benefit to be deposited directly into a financial institution account via EFT?

YesNo

Name the account is held in

BSB Number (6 digits in total)

Financial Institution account number (up to 9 digits only)

Financial Institution

Privacy Consent

I consent to Coverforce Partners Pty Ltd:

(a) Collecting and using my personal information for the purposes of administering my claim including investigating, assessing and paying any claim made by me or on my behalf. (If we do not collect this information we may not be able to process your claim.)

(b) Disclosing my personal information to related entities of Coverforce Partners Pty Ltd, the insured (if not myself), other insurers and reinsurers, insurance reference bureaus, law enforcement agencies, investigators, lawyers, assessors, repairers, advisors and the agent of any of these, insurance broker, insurance agent or other intermediary, my employer or Financial Ombudsman Service Limited (FOS) for the purposes of administering my claim or providing a report.

(c) I understand that a copy of the Coverforce Partners Pty Ltd privacy policy statement, including information about access, may be accessed on our website or by calling 03 8699 8888.

Signature *

Clear

Date *

I / We hereby declare that the forgoing particulars are true and correct in every aspect *

Clear

Date *

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