Claim Form. Aviation Insurance (Hull Damage) T (02) F (02) PO Box R299 Sydney NSW 1225 Australia

Transcription

1 Claim Form Aviation Insurance (Hull Damage) Assetinsure Pty Ltd ABN Pitt Street Sydney NSW 2000 PO Box R299 Sydney NSW 1225 Australia T (02) F (02)

2 This form is issued to enable the Insured to lodge a written statement of claim. It does not constitute an admission of liability on behalf of Assetinsure. IMPORTANT NOTICE Please read the Claim Form fully before answering the questions. Please answer all questions relating to your claim as fully as possible. Use additional sheets if there is insufficient space on this Form. We may contact you for additional information or appoint a loss adjuster or investigator. Please retain any damaged items if possible as they may need to be inspected before settling your claim. Please do not authorise repairs yourself unless in case of urgent emergency repairs necessary to minimise further damage. Please attach all quotations for repair or replacement of damaged property or invoices or receipts for items that have already been replaced in an emergency situation to this Form. Please return the completed Claim Form as soon as possible. A. DETAILS OF INSURED 1. Insured s Full Name Occupation Insured s Address OTHER INTERESTED PARTY Policy Number (if known) ABN Policy Period From / / To / / PERSON TO BE CONTACTED Telephone Fax Address 2. Are you registered for GST purposes? Yes / No 3. Have you claimed, or are you entitled to claim, an ITC for the GST applicable to the policy premium? If so, please specify your percentage entitlement. % 1

3 B. DESCRIPTION OF AIRCRAFT Make / Model Reg No Cert. of registration holder Total number of hours in service Year of manufacture Last maintenance release No: Issued by Issue date Expiry date No. hours at issue Expiry hours C. NATURE OF OPERATION AT TIME OF ACCIDENT Phase of operation (eg flight, taxi) Flight from Flight to Purpose of use (eg private, charter) PARTY FROM WHOM AIRCRAFT WAS Hired or rented (If applicable) PASSENGERS CARRIED (IF APPLICABLE) 2

4 D. DETAILS OF PILOT IN COMMAND Licence No. Telephone No. Type of licence (with endorsements) FLYING HOURS Total On type Last 90 days Last 90 days on type Medical date of expiry Are licence, reviews, renewals, route checks current? Yes / No E. DETAILS OF ACCIDENT Date Time Place Decsribe the circumstances WITNESSES TO ACCIDENT (IF APPLICABLE) 3

5 In 24 hrs prior to accident, had the pilot consumed alcohol? Yes / No In 24 hrs prior to accident, had the pilot taken medication? Yes / No Take off weight of aircraft Reported to A.T.S.B? Yes / No Reported to C.A.S.A.? Yes / No F. BRIEF DETAIL OF DAMAGE OR INJURIES SUSTAINED Aircraft Estimated cost $ Passengers Other persons or property Estimated cost $ 4

6 F. DECLARATION I, (Full Name) Position Of the Insured and on behalf of the Insured declare the above answers to the true and correct in every particular and acknowledge that Assetinsure may make its decision on indemnity having regard to these answers. I consent to Assetinsure using the personal information which I have provided on this form for the purposes of processing this claim. I understand that if I choose not to provide the required details, Assetinsure may not be able to process this claim. I consent to Assetinsure disclosing my personal information to other insurers, an insurance reference service, or as required by law. I also consent to Assetinsure disclosing my personal information to, and/or collecting information about me from, third parties such as investigators or legal advisers. Where I have provided information about another individual (for example an employee or client), I declare that the individual has or will be made aware of that fact. Signature Date COMPLAINTS & DISPUTE RESOLUTION Assetinsure provides an internal claims and dispute resolution process should a dispute or complaint occur. This process is outlined on our website For details contact Assetinsure s Compliance Manager at Assetinsure Pty Ltd, 44 Pitt Street, Sydney 2000, by on complaints@assetinsure.com.au or by calling (02) PRIVACY POLICY The information collected in this form will be used to assess your insurance claim and to provide other insurance services in accordance with our Privacy Policy. We may share your information with third parties, both in Australia or overseas, as defined in our Privacy Policy in connection with providing these services. If you do not complete this form in full we may not be able to pay your claim. In accordance with our Privacy Policy you may access any information we hold about you. If you would like to contact us about Privacy or would like to obtain a copy of our Privacy Policy you can use one of the following means. Online at: By phone on: By to: privacy@assetinsure.com.au By letter to the Privacy Manager at: Assetinsure, 44 Pitt Street, Sydney, NSW 2000 In signing this form you expressly consent to us using your personal information in accordance with our Privacy Policy. GENERAL INSURANCE CODE OF PRACTICE Assetinsure has adopted the General Insurance Code of Practice which stipulates minimum standards of service to our clients. If you would like further information in regard to the Code of Practice please refer to the Code of Practice website - or our own website - 5