JUA Underwriting Agency Pty Limited

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JUA Online Claim Notification Form for General Insurance.
JUA prides itself on responsiveness and prompt settlements. Please submit this Form and a JUA consultant will respond to you within 2 working days.


	Part A - Compulsory for all Claims

	Insurance Broker

	Name of the Insurance Broking Firm:
	Address:

		Suburb: State: Postcode:
	Name of the Insurance Broker:
	Contact details:	Phone :
		Fax:
		Email:


	The insured

	Policy Number:
	Business Name:
	Tax Status:	Registered business: Yes No
		ABN:
		Taxable %:
	Address:
		Suburb: State: Postcode:
	Contact numbers :	Business :
		Facsimile:
		Private:
		Mobile:


	The Property

	Are you the owner of the property being claimed for?
		Yes No - give details

	Was there any other insurance covering this damage current at the time of the occurrence?
		No Yes - give details
		Name of Insurer:
		Policy Number
	Does any other party have an interest in the damaged property the subject of the claim? (e.g. Mortgagee, Finance Co. leasee)
		No Yes - give details
		Name
		Telephone


	The Premises

	At what address did the loss occour?

		Suburb: State: Postcode:
	Describe the premises (i.e. Factory, Warehouse, Office Block etc.)

	Are the premises tenanted?	No Yes - give details of tenant
	Are you the tenant?	No Yes - give details of building owner
	Were the premise occupied at time of the loss?
		Yes No - give details of when last occupied
		Name:
		Hour	Date:


	Incident details

	Day and Date of Incident
	Between the hours of	and
	How did the damage/loss occur?
	Was another person responsible for the damage?
		No Yes - give details
		Name
		Address
		Suburb: State: Postcode:


	Part B - Complete relevant sections pertaining to your claim

	Breakage of Glass - Please attach invoice or quotation

	What was broken?
	Was the break through the entire thickness of the material?
		Yes No
	Has the break been repaired?
		No Yes - If yes, have you paid the account? Yes No
	Was there damage to window signwriting?
		Yes No


	Storm and Water Damage

	Describe the damage:
	How did the Wind, Rain or Water enter the premises?

	Did the storm cause this opening?
		No Yes - give details


	Theft or Burglary

	Please attach original purchase dockets, invoices or receipts. If you provide us much proof about owning items the items it will help us to process your claim quickly.
	How were the premises entered and where was the point of entry?

	Which parts of the premises were entered?

	Have the police recovered any property?
		No Yes - give details


	Security Details

	Are any of these used to provide security to the premises?
		Keyed window locks on all accessible windows		Internal Alarm
		Double keyed deadlocks on all perimeter doors		Fixed Safe
		Back to base (please attach activity report		Free standing safe
		Grilles on all accessible windows and doors		None
		Perimeter Alarm
	Did the device activate as a result of theft? Yes No
	Note: Any loss involving malicious damage, lost or stolen property must be notified to the police


	Police Details

	Have the police been notified?	No Yes - by whom?
		Name
		Police Station
		Crime Report No.
		Telephone
		Date notified
	If the damage is the result of fire did the fire brigade attend?
		Yes No
	Please attach a copy of Police Report, if available.


	Part C - Compulsory completion for all Claims

	Details of Claim

	Please attach quotations to this online Claim, or fax them to us. If insufficient space please attach list and show total amounts only below. Damage Building
	Particulars	Name of Repairer	Amount Claimed
			$ $ $ $ $ $
		Total:	$

	Loss or Damage to other Property
	Description of Property (Include Serial Number)	Where Purchase	When Purchase	Value atTime of Loss	Replacement Val. (attach quotes)
				$ $ $ $ $ $	$ $ $ $ $ $
	Total:				$
	We are not responsible for payment of invoices, however, please indicate if you request payment to any other party.


	Privacy

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	Declaration and Authorisation

	The information and answers given above are true and complete in every detail. I understand the claim may be refused, delayed or reduced if information is withheld. I authorise that JUA Underwriting Agency Pty Limited give to and obtain from other insurers, insurance reference bureaus and credit reporting agencies any information relating to the Insured's credit or insurance history as well as insurance claims information obtained during the course of this contract.
	Name
	Date
	How do you want to send this form to JUA? Please select an option:
		OR	Instantly submit this form to JUA via the internet now. Please fax any necessary attachments to: (02) 9247 2411. Please note that you can Print your Claim Notification details in the next screen.
			Print your Claim Notification details, sign it and fax to: (02) 9247 2411. Remember to also fax any necessary attachments.