Claims - Salon Insurance: Hair & Beauty Industry Insurance Specialists

Policy Details

Full Name(s) of Insured:*

Address of Insured:*

Street Address City State Postcode Country

Telephone Number:

Insurer:

Policy No:

Expiry Date:

DD slash MM slash YYYY

General Details of Loss / Damage

Where did event occur?

Date of Event

DD slash MM slash YYYY

Approximate time of loss / damage

Hours

Minutes

AM/PM

Brief description (including cause of loss or damage)

Is any Third Party to blame for loss or damage?*

Yes

If yes, please give details

Have you received, or do you anticipate receiving, notice of any claim from or on behalf of Third Parties?*

Yes

If yes, please give details

Give details of all witnesses, if any:

Name

Address

Postcode

Were the Police notified?*

Yes

If yes, please give details

Date of Report:

DD slash MM slash YYYY

Name of Police Station:

Have you taken any action to recover or reduce your loss?*

Yes

If yes, please give details

Other Particulars

Name of Owner of property lost / damaged

Name of any other interested party (eg, Mortgagee, Trustee)

Details of any other insurances covering lost/damaged property

Are you a registered business?*

Yes

What is your ABN?

What percentage of GST in your premium did you claim as an Input Tax Credit for the period of insurance in which this loss occurred?

Please provide bank account details, should you wish for claim settlement to be paid into your account;

Bank Account Name:

BSB:

Account Number:

Declaration

I/We, the undersigned claimant(s) hereby declare that the foregoing statements and particulars of the claim are true and correct and that I/We have not withheld any information relevant to this claim.

I expressly agree that the information given by me is provided with my full knowledge and consent and further agree to hold harmless and indemnify Direct Insurance Brokers Pty Ltd in the event of any action or matter that may be taken by any party pursuant to the Privacy Act 1988 (Cth).

Full name of claimant(s)*

Schedule

Please complete for Loss of property

Description of property for which loss is claimed

Date of Purchase or Acquisition

Original Cost

Value at time of Lossallowing for reasonable Depreciation

Value of Salvage (if any)

Amount of Loss or Damage Claimed ($)

Total amount of Loss claimed*

Please complete for Damage to property

Particular

Name of Repairer (Invoice / Quote)

Cost of Repairs ($)

Total Repairs*

Total amount claimed*

Please complete for Fusion damage

Machine / Appliance

Maker

Date of Purchase

H.P. of Motor

Name of Repairer Invoice/Quote Attached

Cost of Repairs ($)

Total repairs*

(Note: To Avoid delay, attach invoice giving the separate items of costs as certain items may not be claimable)

Invoices

Drop files here or

Max. file size: 8 MB.

Less Excess*

Net amount claimed*

Third party claims

Name*

First Last

Address*

Street Address City State Postcode Country

Occupation

Nature and extent of injuries/damage

Has the third party any relationship to you?*

(eg. relative, employee)

Have you received any correspondence from third parties?*

Yes

If yes, please enclose them*

Have you made any admission of liability?*

Yes

If yes, please specify*

Name

This field is for validation purposes and should be left unchanged.