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Policy holder name*

Insured address*

Contact number*

Email*

Policy number (if known)

Loss date*

Loss time*

Type of claim* Type of claim* Accidental damage Fire/bushfire Spoilage Burglary/theft Glass breakage Storm Cyclone Malicious Damage Water damage Other

Severity of Damage* Severity of Damage* A - Significant damage to the home, unliveable B - Moderate damage to the home, unliveable C - Moderate damage, still able to live in home D - Minimal damage, still able to live in home

Details of damage/what happened

Has the roof of your home been damaged allowing water into the home?* Has the roof of your home been damaged allowing water into the home?* Yes No

Do you require emergency repairs to make the home safe & secure?* Do you require emergency repairs to make the home safe & secure?* Yes No

If yes what is required?

Do you require assistance with emergency accommodation?* Do you require assistance with emergency accommodation?* Yes No

If yes what is required?

Are there any special circumstances you would like us to be aware of ?* Are there any special circumstances you would like us to be aware of ?* Yes No

If yes what is required?