360 Commercial

Claim Form
360 Commercial Pty Ltd ABN 73 620 071 650 is an Authorised Representative (AR 1256191) of
360 Underwriting Solutions Pty Ltd ABN 18 120 261 270, AFSL 319181
The Forum, Level 3, 240 Pacific Highway, Charlestown, NSW 2290
360 Commercial
Claim Form
In the Event of a Claim Complaints and Dispute Resolution
++ Please take immediate and reasonable steps to ensure We view seriously any complaint made about our products or
that no further damage or loss occurs to the property. services and will deal with it promptly and fairly.
++ No repairs are to be commenced without our consent. If you have a complaint please first try to resolve it by contacting
++ If any third party holds you responsible for their loss or the relevant member of our staff.
damage, please ask them to put their claim in writing.
If the matter is still not resolved, please then contact our Internal
++ Do not admit liability to any third party and do not Disputes Resolution Officer on 02 9047 9814 or by email at
disclose that you may have insurance in place. [email protected] or by writing to us at the address for
++ Any salvage remains the property of the insurer. 360 Underwriting Solutions Pty Ltd given below. They will seek to
++ Contact your Broker if you are unsure about any resolve the matter in accordance with the General Insurance Code
matters relating to completion of this Claim Form. of Practice and our Dispute Resolution procedures.
If the matter is still not resolved, or you are not satisfied with the way
How to Fill in the Claim Form a complaint has been dealt with we will provide you with information
++ The completion of this form does not constitute policy about the Australian Financial Complaints Authority (AFCA) including
acceptance by the insurer. their contact information.
++ Failure to notify a matter immediately after the event or
after you become aware of the event may enable the Privacy Statement
insurer to reduce or avoid any liability incurred. We are committed to protecting your privacy in accordance with the
++ This Claim Form should be completed in full and Privacy Act 1988 (Cth) and the Australian Privacy Principles (APPs).
honestly. Please sign and return it to your Broker
The information provided in this document and any other documents
as soon as possible with any relevant photos and
provided to us will be dealt with in accordance with our Privacy
attachments.
Policy. By executing this document you consent to collection, use
++ If insufficient space is provided, please attach separate storage and disclosure of your personal information in accordance
sheet(s) and sign and date each sheet attached. with our Privacy Policy. If you do not provide the personal information
++ Incomplete, illegible or unclear answers will delay requested or consent to its use and disclosure in accordance with our
processing of your claim. Privacy Policy, we may not be able to adequately handle your claim.
++ To ensure prompt action, please submit ALL Our Privacy Policy explains how we collect, use, hold, disclose and
documentation to [email protected] handle your personal information including transfer overseas and
provision to necessary third parties as well as your rights to access
and correct your personal information and make a complaint for any
General Insurance Code of Practice breach of the APPs.
In accordance with our binding authorities, where we act on behalf of A copy of our Privacy Policy is located on our website at
the insurer, we are bound by the General Insurance Code of Practice www.360uw.com.au
(The Code). The Code is designed to set minimum standards of
practice and service in the insurance industry. Please access and read this policy. If you have any queries about
how we handle your personal information or would prefer to have a
Further information about The Code can be obtained from copy of our Privacy Policy mailed to you, please ask us.
www.codeofpractice.com.au
If you wish to access your file please ask us.
Agent of Insurer
In accordance with the requirements of the Corporations Act 2001
(Cth), 360 Commercial Pty Ltd in arranging or effecting this insurance
or dealing with or settling claims will be acting under an authority
given to it by certain insurers. Accordingly, 360 Commercial Pty Ltd
will be acting as an agent of the insurers and not an agent of the
insured.

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Policy Details
* Insured ABN Policy No.

To what extent can you claim an input tax credit on your insurance premiums?
%
Address

City State Postcode

* Contact Name * Telephone

* Mobile Fax Email

Insurance Broker
Name of your Insurance Broker

Address

City State Postcode

Contact Name Telephone

Mobile Fax Email

Description of Loss
Day of Incident * Date of Incident Time AM PM

* Please describe what happened

Address of the loss, theft or damage?

Who discovered the loss, theft or damage?

* Date Discovered Time AM PM

* Mandatory fields must be completed

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 Are you the owner of the property being claimed for? Yes No
If no, give details

Does any other party have an interest in the property being claimed for? Yes No
If yes, give details

Is there any other insurance policy which would cover this loss, theft or damage? Yes No
If yes, give details

Do you know who is responsible for the loss, theft or damage to your property? Yes No
Please advise name(s) and address(es) of the person(s) responsible

Security Details
Are any of these used to provide security to the premises? Please tick which apply

Key window locks on all accessible windows? Grilles on all accessible windows and doors?
Double keyed deadlocks on all perimeter doors? Fixed safe?
Perimeter alarm? Freestanding safe?
Internal alarm? None

If there is an alarm, was it activated? Yes No

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Police
Was this loss, theft or damage reported to the police? Yes No
Date of Incident Crime Report No.

Name of Police Officer

Name of Police station where loss, theft or damage was reported

Fire
If the damage is the result of fire, did the fire brigade attend? Yes No
Where did the fire commence?

Details of previous loss, theft or damage

Have you ever suffered any loss, theft or damage at this address or elsewhere in the last 5 years? Yes No
If yes, please give details

Type Date Total Amount

$

Have you made a claim on any insurer for any of the above mentioned incidents? Yes No
If yes, please give details

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 Insurer Date Total Amount
$

Details of Claim
Please attach 1 repair quotation, where available. If insufficient space please attach list.

Damage to building
Particulars Name of repairer Amount Claimed
$

Loss or damage to other property

Description of property Where purchased When purchased Value at time of loss Replacement Value
(Attach Quotes)
$ $

$ $

$ $

$ $

$ $

$ $

TOTAL $

Where possible attach original invoices, receipts or other proof of purchase. This will help us in assessing your claim as quickly as possible.

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Electronic Funds Transfer Details
If your claim is accepted, your claim benefits can be transferred directly into your bank account.
Please provide the following details:
Name of Financial Institution Account Name

BSB Account No Bank SWIFT code (if required)

Declaration and Authorisation

I declare that to the best of my knowledge and belief the details given are true, correct and complete in every respect. I understand
that if a claim is intentionally exaggerated or fraudulent the claim may be refused and no payment will be made.

I confirm that I have read and understood the Privacy Statement and consent to the collection, storage, use and disclosure of
personal and sensitive information to all persons affected by this claim. I understand that I do not agree to the collection of this
personal information then 360 Commercial Pty Ltd and/or the Insurer(s) it acts as agent for will be unable to process the claim.

* Signature of Insured

* Date

* Print Name

* Signature of Witness

* Date

* Print Name

* Mandatory fields must be completed

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360CCFV319
 NSW
Level 18, 201 Kent St
Sydney, NSW 2000

The Forum, Level 3

240 Pacific Highway
Charlestown, NSW 2290

VIC
Level 9, 99 William St
Melbourne, VIC 3000

QLD
Level 8, 500 Queen St
Brisbane, QLD 4000

SA
PO Box 1166
Nairne, SA 5252

WA
PO Box 864
Joondalup DC WA 6919