Business Insurance Claim form

Policy Information

Policy Number*

Insured (surname, company or partnership)*

Name of person completing form*

Occupation*

Home Phone*

Business Phone

Mobile

Email*

Preferred method of contact*

Phone
Email
Mail

Have you claimed or do you intend to claim an input tax credit on the GST applicable on this policy?*

Yes
No

Is the amount claimed or intended to be claimed less than 100% of the GST applicable to the premium?*

Yes
No

Specify the percentage claimed or intended to be claimed*

Bank details

Name of account*

BSB*

A/C Number*

Bank name*

Loss or damage

Date and time of loss*

:

On*

Location of loss or damage*

Are you the only occupier of the premise, if not specify other occupants

Yes
No

Other Occupants*

Who discovered the loss or damage?*

Were there any witnesses to the loss or damage?

Name & contact details of witnesses

Select type of claims*

Burglary
Fire/perils
Glass
Liability
Machinery & Electronic Breakdown

Were the premises broken into*

When were the premises last occupied?*

Were the premises securely locked?*

How was entry gained?*

What steps will you take to improve security?*

Was this incident reported to the police?*

Yes
No

Police report details (date reported, name of police officer, police office report number )*

Details of what was stolen/damaged*

Is any property repairable?

Are quotes attached?*

Yes
No

Do you have original receipts, valuations or quote for replacement or certificates from an authorised repairer for any item stating its unrepairable?*

Yes
No

Do you owe any money on the property stolen or damaged?*

Yes
No

What was the damage caused by*

Fire
Water damage
Wind

Please explain what happened*

If fire damage, provide details of fire station

Please provide details of what was damaged*

Is any property repairable?*

Are quotes attached?*

Yes
No

Do you have original receipts, valuations, quotes for replacement or certificates from an authorised repairer for any item stating its unrepairable?*

Yes
No

Do you owe any money on the property damaged?*

Yes
No

What type of glass has been damaged?*

External door
Windows

What happened*

State clearly how the accident happened*

Have you received any indication that a demand or claim will be made upon you for the accident or incident?*

Yes
No

What Kind of Indication?*

Was the accident reported to the police or workcover?*

Yes
No

Details of the report*

Was there a witness?*

Yes
No

Enter name, Address and Phone no*

Details of machine – make & year of manufacturer*

Type*

Model*

Serial Number*

HP/KW*

What happened?*

Estimate cost of repairs*

Is quote for replacement or invoice enclosed*

Yes
No

Spoilage of food

Was there any food spoilage?*

Yes
No

Where are the damaged goods now?*

What was the value of the goods damaged?*

Have you replaced the items destroyed?*

Yes
No

Have you attached a list?*

Yes
No

Pictures and Documents

Upload up to 3 documents and pictures below.

Max. file size: 100 MB.

GST

The limits of cover that You choose should exclude Goods and Services Tax (GST).

If You are not registered for GST in the event of a claim We will reimburse You the GST component in addition to the amount that We pay.

The amount that We are liable to pay under this Policy will be reduced by the amount of any input tax credit that You are or may be entitled to claim for the supply of goods or services covered by that payment.

If You are entitled to an input tax credit for the premium, You must inform Us of the extent of that entitlement at or before the time You make a claim under this Policy. We will not indemnify You for any GST liability, fines or penalties that arise from or are attributable to Your failure to notify Us of Your entitlement (or correct entitlement) to an input tax credit on the premium.

If You are liable to pay an excess under this Policy, the amount payable will be calculated after deduction of any input tax credit that You are or may be entitled to claim on payment of the excess.

Duty of disclosure

Before you enter into an insurance contract, you have a duty to tell us anything that you know, or could reasonably be expected to know, may affect our decision to insure you and on what terms.

You have this duty until we agree to insure you. You have the same duty before you renew, extend, vary or reinstate an insurance contract.

You do not need to tell us anything that:

reduces the risk we insure you for; or
is common knowledge; or
we know or should know as an insurer; or
we waive your duty to tell us about.

If you do not tell us something If you do not tell us anything you are required to, we may cancel your contract or reduce the amount we will pay you if you make a claim, or both.

If your failure to tell us is fraudulent, we may refuse to pay a claim and treat the contract as if it never existed.

Privacy

QBE includes information about how we manage your personal information in our Product Disclosure Statements and Policy booklets.

You can obtain a copy of the QBE Privacy Policy Statement from our website www.qbe.com or contact the Compliance Manager on 02 9375 4656 or email compliance.manageraqbe.com for further information.

Declaration and Authorisation

I certify that:

I am authorised to submit this claim as:
- the insured person,
- a broker who has been appointed as the agent of the insured person, or
- an authorised representative of the insured person, or
I am authorised to provide this information to you for the purpose of making this claim; and
the information given in this form is truthful, accurate and complete, and no information likely to affect this claim has been withheld. I understand that this claim may be refused if information is untrue, inaccurate or concealed.

I declare that, to the best of my knowledge and belief, the information in this form is true and correct and I understand the claim may be refused or reduced if information is withheld.

I understand that I may have to provide relevant documentation to enable complete consideration of my claim.

I consent to QBE Insurance (Australia) Limited Insurance and/or its agents using the personal information I have provided on this form for the purposes of processing my claim. I consent to the disclosure of sensitive information to third parties in order to process this claim including, but not limited to:

Intermediaries through which I deal with QBE Insurance (Australia) Limited Insurance (for instance an agent, broker or financial advisor);
Claims assessment participants (for instance an assessor, investigator and/or loss adjuster);
Other reputable service providers (for instance mail houses); and
Underwriters, who are responsible for part or all of the risk under a contract of insurance (for instance a reinsurer).

I consent to the disclosure of any personal information (including sensitive information) overseas where it is reasonably necessary for the processing of the insurance claim. I understand that if this consent is not given, QBE Insurance (Australia) Limited Insurance and/or its agents will not be able to process this insurance claim.

Declaration*

I have read, understood and agree to the declaration and privacy statement.

Enter Name*

Date*

CAPTCHA

The information and answers given above are true, correct and complete in every detail.

I/We understand the claim may be refused if information is not true or is withheld.
I/We authorise QBE Insurance (Australia) Limited to give to and obtain from other insurers, insurance reference bureaus and credit reporting agencies any information relating to the Insured's credit or insurance history as well as insurance claims information obtained during the course of this contract.

Lodge Your Claim