General Insurance Claim – Tony Jordan Insurance
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General Insurance Claim

  • Description of loss or damage

  • To assist in assessing the loss, the following information is requested.
  • Description 1
  • *Please show the Input Tax Credit you are entitled to claim on the purchase of each item as a percentage of the total GST payable.
  • Description 2
  • *Please show the Input Tax Credit you are entitled to claim on the purchase of each item as a percentage of the total GST payable.
  • Description 3
  • *Please show the Input Tax Credit you are entitled to claim on the purchase of each item as a percentage of the total GST payable.
  • Details of Loss Damage or Occurrence

  • Responsibility/Witnesses

  • Insurance History

  • Privacy

  • The Privacy Act 1988 requires us to tell you that we as broke and the insurer collect your personal and sensitive information in order to calculate your loss and entitlements, determine the insurer’s liability, compile data and handle claims. When handling claims we and the insurer may have to disclose your personal and other information to third parties such as other insurers, reinsurers, loss adjusters, external claims data collectors, investigators and agents, or other parties as required by law. Where you give us information about other persons you must have their consent to this and provide it on their behalf. If not, you must tell us. You have the right to seek access to your personal information and to correct it at any time. Please contact us to advise if any changes are required.
  • Internal Dispute Resolution (IDR) Statement

  • Disputes are not an everyday occurrence. However insurers provide an internal dispute resolution process should any dispute arise. Please feel free to ask for details. If you are not satisfied with the outcome of that process, we will advise you how to contact the insurance industry’s external independent complaints scheme (subject to eligibility).
  • Declaration

  • 1. I/We the insured do solemnly and sincerely declare that I/We have complied with the conditions and warranties (if any) of the policy and have not deliberately caused the said loss or damage or sought unjustly to benefit thereby by any fraud or misrepresentation and that the information shown on the form is true and the I/We have not concealed any information relating to this claim. I/We understand that this claim may be refused if the information is untrue, inaccurate or concealed. 2. Further it is understood and agreed that if any property claimed for is subsequently recovered in an undamaged condition I/We will immediately refund the company any sum which may have been paid to me/us in respect of such property. In the event of any property being recovered in damaged condition I/We will immediately hand the same over to the company for disposal as may be agreed. 3. I/We acknowledge that I/We have read and understood the Privacy Act information referred to above and consent to the collection, storage, use and disclosure of personal and sensitive information of all persons affected by this claim. 4. I/We acknowledge that if I/We do not agree to the collection of this personal and sensitive information, then the broker and the insurer will be unable to process my/our claim.
  • Please provide bank details in order for your claim payment to be settled via EFT.
  • This field is for validation purposes and should be left unchanged.


Authorised Representative of Community Broker Network Pty Ltd
ABN 60 096 916 184 | AFSL 233750

Authorised Representative of Chaucer Group
ABN 88 607 427 261 | AFSL 480318

CAR No: 1256403

Postal Address
2/17 Palm Avenue,
Bongaree
QLD 4507
Financial Service Guide
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vickym@wgib.com.au

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