General Property Insurance
Claim Form
Contact Willis Towers WatsonIf you have any questions or concerns please contact us:
Willis Towers Watson Claims
Willis Towers Watson Email:
Level 4 555 Bourke Street Telephone: 1300 854 544
Melbourne VIC 3000 Australia
If there is not sufficient space on this form for your answers, please attach a separate sheet, indicating the Section and Question you wish to complete. / Claim No
Policy Details
Full Name(s) of Insured / Address of Insured
Telephone No: (A/H) / Telephone No: (B/H) / Suburb / State / Post Code
General Details of Loss/Damage
Date of loss/damage / Approx time of loss/damage
// / am/pm
Location of loss / damage
Nature of Loss i.e. Fire, burglary etc.
Are you the owner of the lost / damaged property?
YES NO / (If no, please state name(s) and address(s) of all other parties and their interest in the property):
How was the loss/damage discovered?
Were the Police notified? / Police Report No.
YES NO / Please attach a copy of the police report
(If yes, please state):
Date of Report / Approx. time of report / Name of Police Station / Name of Police Officer
// / am/pm
Has any property been recovered?
YES NO / (If yes, please give details)
Was any other party responsible for the loss/damage?
YES NO / (If yes, please give details)
Statement of Claim – Please Include Quotations for Replacement and/or Repair, Original Receipts for Proof of Ownership
Description of Property lost, stolen, damaged, destroyed / Date and Location of Original Purchase / Original Purchase Price / Quoted Replacement Cost / Net Amount Claimed
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
Complete For All Claims - ABN Details
Are you a registered business? / What is your ABN? / What percentage of GST in your premium did you claim as an Input Tax Credit for the period of insurance in which this loss occurred?
YES NO / %
Electronic Funds Transfer
Settlement of your claim may involve some cash settlement. Please complete the below to receive funds by EFT.
Account Name / BSB Number / Account Number
Declaration
I/We, the undersigned claimant(s) hereby declare that the foregoing statements and particulars of the claim are true and correct and that I/We have not withheld any information relevant to this claim.
I expressly agree that the information given by me is provided with my full knowledge and consent and further agree to hold harmless and indemnify Willis Towers Watson in the event of any action or matter that may be taken by any party pursuant to the Privacy Act 1988 (Cth). I/We acknowledge that I/we have read and understood the paragraphs accompanying this proposal headed “Your Privacy”.
Full name of claimant(s)
(please use block letters) / Position/Title / Signature(s) / Date
//
//
Your Privacy
Notice of Collection of Personal Information
In order to arrange insurance for you or to handle a claim for you, Willis Australia Limited (“Willis Towers Watson”) needs to collect your personal information (which may include, depending on the circumstances, sensitive information about you such as information about your health). Willis Towers Watson will use your personal information to provide such insurance-related services to you, and also for other related purposes, such as: (1) complying with legal and regulatory requirements; (2) improving and developing the services Willis Towers Watson provides; and (3) contacting and maintaining the relationship between Willis Towers Watson and you.
For such purposes, Willis Towers Watson may share your personal information with: (1) third parties who are relevant to the services Willis Towers Watson provides, such as insurers and claims handlers; (2) third parties who support Willis Towers Watson’s business operations, such as IT service providers, administrative support service providers; and (3) where applicable, third parties with whom Willis Towers Watson is by law required to share your personal information, such as regulators or courts/tribunals. Such sharing of your personal information may result in your personal information being transferred overseas, including the UK, USA, and India.
It is not mandatory for you to provide your personal information when requested by Willis Towers Watson, but if you do not agree to the collection or subsequent use of your personal information by Willis Towers Watson, this might prevent Willis Towers Watson from arranging insurance or handling claim for you and that might in turn adversely affect you. If you wish to learn more about how Willis Towers Watson handles your personal information, please refer to Willis Towers Watson’s Privacy Policy which is available online at http://www.willis.com/Subsites/Australia/documents/Privacy_Policy.htm or upon request. If you have any questions or concerns regarding how your personal information is handled by Willis Towers Watson, please contact the Privacy Officer at: Willis Towers Watson, Level 16 Angel Place 123 Pitt Street Sydney NSW 2000 Australia, E-mail: , Telephone: 02 9285 4068.
Willis Towers Watson General Property Insurance Claim Form