Property Claim Form
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1
2Property Claim Form
Property
Personal and Commercial
The supply or acceptance of this form is not an admission of
liability on the part of Allianz.
RESET FORM
Claim Number
Name of Insured:
Occupation
Contact Person
Home Phone No.
Work Phone No.
Mobile No.
Email
Occupation
Postal Address
Postcode
Broker/Agent Name
Phone No.
Policy No.
Excess $
Inception Date
Expiry Date
■ ■
■ ■
Interested Parties: Is the property being claimed for under a Financial Agreement?
Yes
No
Name of Financier
Contract No.
■ ■
■ ■
G.S.T.: Are you registered for GST purposes?
Yes
No
A.B.N.
To what extent are you entitled to claim an Input Tax Credit on the GST for this policy?
%
Incident Description: What happened, how (eg. if burglary, include how entry was gained and details of forced entry)
and the name of any party who caused damage etc?
Date of Loss
Time of Loss
Type of Loss
Address Where Loss Occurred
Postcode
Date premises last occupied
Name of last occupier
Schedule (if insufficient space, provide separate list):
* Please show the extent to which an ITC can be claimed by you on each item
* All original repair invoices, quotes or receipts must be submitted to avoid any delays in processing
* Show all values in Australian Dollars
Description of property lost/damaged/stolen
(include names of owners of items if not owned by
Year
Where
Replacement or
Amount
ITC%*
the insured)
Purchased
Purchased
Repair Cost
Claimed
Entitlement
$
$
$
$
$
$
$
$
$
$
Total Claimed
$
(If insufficient space, attach list).
Allianz Australia Insurance Limited AFS Licence No. 234708 ABN 15 000 122 850 Registered Office: 2 Market Street Sydney NSW 2000
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Parent category: Business