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Link Insurance | Licensed Insurance Brokers for Commercial and Industrial Enterprises

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Cullclear Life

Fire, Impact, Storm & Tempest Insurance Claim

Policy Number:
Due Date:
Insured Details
Full Name*
First Last
Email*
Address*
Street Address City State Post Code
Business Phone*
Mobile Phone*
Fax No.
Occupation/Business/Industry/Trade
Name any other interested party
How interested
Address
Street Address City State Post Code
Is there any other Insurance in force which would cover this in whole or part?
- Yes
- No
Please advise
Insurer’s Name
Policy Details
What is your Australian Business Number (ABN)?
Are you registered for GST?
- Yes
- No
To what extent are you entitled to claim an Input Tax Credit on the GST applicable to the premium? (%)*
Details of Loss Damage Or Occurrence
Date of Loss / Damage / or Occurrence
MM slash DD slash YYYY
Time
When was it reported to you (if applicable)?
MM slash DD slash YYYY
Time
Place and/or premises where it occurred
Please state full details of how loss/damage/accident occurred
Please describe nature of damage or injury
What steps have you taken to minimise the loss?
If Storm & Tempest, through what type of opening did wind, rain or water enter the premises?
Did Storm & Tempest cause opening to premises?
- Yes
- No
Describe the cause.
If dividing fence or wall damage, give name and address of joint owner.
If damage caused by vehicle, give names & address of owner/driver & vehicle registration number.
Responsibility/Witnesses
In your opinion was any other person(s) responsible for loss or damage Or cause of the Occurrence?
- Yes
- No
Please give full details.
Name
First Last
Address
Street Address City State Post Code
Business Phone
Private Phone
Fax No.
Reasons
Was there a witness or witnesses to this event?
- Yes
- No
Please give full details
Name of Witnesses
Witnesses’ Address
Street Address City State Post Code
Business Phone
Private Phone
Fax No.
Description of property loss or damage
Description 1
Description
Sum Claimed $
Date of purchase
From whom purchased
Purchase Price $
Replacement Value $
*Input Tax Credit %
*Please show the Input Tax Credit you are entitled to claim on the purchase of each item as a percentage of the total GST payable.
Total amount claimed $
Description 2
Description
Sum Claimed $
Date of purchase
From whom purchased
Purchase Price $
Replacement Value $
*Input Tax Credit %
*Please show the Input Tax Credit you are entitled to claim on the purchase of each item as a percentage of the total GST payable.
Total amount claimed $
Description 3
Description
Sum Claimed $
Date of purchase
From whom purchased
Purchase Price $
Replacement Value $
*Input Tax Credit %
*Please show the Input Tax Credit you are entitled to claim on the purchase of each item as a percentage of the total GST payable.
Total amount claimed $
Description 4
Description
Sum Claimed $
Date of purchase
From whom purchased
Purchase Price $
Replacement Value $
*Input Tax Credit %
*Please show the Input Tax Credit you are entitled to claim on the purchase of each item as a percentage of the total GST payable.
Total amount claimed $
Description 5
Description
Sum Claimed $
Date of purchase
From whom purchased
Purchase Price $
Replacement Value $
*Input Tax Credit %
Total amount claimed $
*Please show the Input Tax Credit you are entitled to claim on the purchase of each item as a percentage of the total GST payable.
Description 6
Description
Sum Claimed $
Date of purchase
From whom purchased
Purchase Price $
Replacement Value $
*Input Tax Credit %
Total amount claimed $
*Please show the Input Tax Credit you are entitled to claim on the purchase of each item as a percentage of the total GST payable.
Insurance History
Have you ever previously sustained loss/damage or caused damage or injury to 3rd parties
- Yes
- No
Give details of such losses and amounts involved.
Was an Insurance Company involved?
- Yes
- No
Please state name of company and year of claim.
Have you been convicted of or had any fines or penalties imposed for any criminal offences in the last 10 years?
- Yes
- No
Please provide details.
How would you prefer us to contact you?*
- Phone
- Email
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Link Insurance Brokers Pty Ltd

AFSL 238479
ABN 26 988 418 405

Toll Free
1300 131 343

Taringa Office
Suite 101, 35 Morrow Street
Taringa QLD 4068

Postal Address
PO Box 333
Indooroopilly QLD 4068

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