Notification of a Claim

Policy Holder Name(*)

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Are you GST registered?(*)

YesNo

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Policy Number(*)

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What percentage of your premium do you claim GST on?

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Your Name(*)

Please type your full name.

Contact Number(*)

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Relationship to Insured(*)

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E-mail(*)

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Loss / Incident Location

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Date of Loss or Incident

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Description of Loss/Incident

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Upload supporting documents (e.g Photos of damages, repair invoices/quotes, witness statements). We accept PDF, JPG & PNG(*)

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