Property Claim Form - LJM Insurance

1. Insured Or Company Details
Insured name or company*
Policy number (if known)
Point of contact
Phone number
Email
Are you registered for GST purposes?
- Yes
- No
Do you have an ABN?
- Yes
- No
ABN
2 . Claim Details
Location at which loss or damage occurred
Suburb
State
Date of loss or discovery*

MM slash DD slash YYYY
Summary of claim
(If this is a theft claim), please provide further details
File upload
Drop files here or

Max. file size: 30 MB, Max. files: 12.
Please provide documentation to support your loss (photographs, quotes, original invoices, reports, or any other supporting evidence)
Have the police been notified?
(Yes is required for malicious damage or theft/burglary claims)
- Yes
- No
If known, please provide:
Officer name
Police station
Police report number
Phone number
3. Details Of Any Third Party If You Feel They Are Responsible For The Loss
Name
Phone number
Address

Street Address

Address Line 2

Suburb

State
Vehicle registration number
(if applicable)
4. Details Of Repairs Taken Place Or Temporary Repairs Completed

Please provide documentation to support your loss (photographs, quotes, original invoices, reports, or any other supporting evidence)
Details Of Repairs
List

Item being claimed Month & year of purchase Original purchase amount Quote to replace or repair
5. Electronic Funds Transfer Details

Following insurer’s approval of your claim, should you wish to have your funds transferred directly into your bank account, please provide the following details
Name of financial institution
Account name
BSB
Account number
6. Declaration

I declare that to the best of my knowledge and belief the information in this form is true and correct and I have not withheld any relevant information.
I/we agree that, by submitting this form, the personal information I/we provide to PSC Connect Pty. Ltd. in this form or otherwise may be collected, held,
used and disclosed in the manner set out in the PSC Privacy Policy found at www.pscconnect.com.au/privacy, including for processing this claim.
Name
Date

MM slash DD slash YYYY
Confirmation
- I confirm that the details I have entered are correct

Item being claimed	Month & year of purchase	Original purchase amount	Quote to replace or repair

1. Insured Or Company Details

2 . Claim Details

3. Details Of Any Third Party If You Feel They Are Responsible For The Loss

4. Details Of Repairs Taken Place Or Temporary Repairs Completed

5. Electronic Funds Transfer Details

6. Declaration

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