EQUINE & LIVESTOCK INSURANCE CLAIM FORM
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1 EQUINE & LIVESTOCK INSURANCE CLAIM FORM The provision of this form by A.I.S. Insurance Brokers Pty Ltd is not an admission of liability or acceptance by A.I.S. Insurance Brokers Pty Ltd of your claim. Insured/s name in full: Date of Birth Are you registered for GST: Yes No If Yes, ABN No: ITC Proportion Postal Address: Phone Number (Office Hours): Mobile Number: Address where animal was kept: Address: Policy Number: DESCRIPTION OF ANIMAL CLAIMED (if insufficient space attach schedule) Name Breed Brand & Colour Sex Date of Birth Sum Insured $ GENERAL QUESTIONS - All must be fully answered (attach further details if insufficient space) 1. Date and time veterinary surgeon first attended? AM / PM 2. Name and address of veterinary surgeon? Enclose a copy of the veterinary report, diagnosis & autopsy to this claim for the animal. 3. Type of Claim Mortality/Theft Loss of Use 4. Give the date and time that the animal died or was destroyed: AM / PM 5. What was the current value of the animal at the time of occurrence and why? : $ Page 1 of 5
2 6. Give the date and place that the animal sustained the injury: 7. Cause of illness or injury? 8. Who was in charge of the animal at the time of the illness or injury? 9. If illness or injury was caused by the apparent negligence of any person, give name, address, occupation and reason for you thinking so? 10. Was salvage obtained from the carcass, if so please enter amount and receipt? $ 11. Give details of previous treatment or medication administered to this animal whilst in your possession? 12. Have you received livestock insurance payments before? If yes, please provide details: 13. Was the animal, now the subject of this claim, insured elsewhere? 14. Has any other person or company any financial interest in this animal? If so please give their name and address and state their interest: 15. Have you ever had: i any insurance claim declined? Yes No ii any insurance Certificate declined? Yes No Page 2 of 5
3 PRIVACY CONSENT I consent to A.I.S. Insurance Brokers Pty Ltd: (a) (b) (c) Collecting and using my personal information for the purposes of administering my claim including investigating, assessing and paying any claim made by me or on my behalf. (If we do not collect this information we may not be able to process your claim.) Disclosing my personal information to related entities of A.I.S. Insurance Brokers Pty Ltd, the insured (if not myself), other insurers and reinsurers, insurance reference bureaus, law enforcement agencies, investigators, lawyers, assessors, repairers, advisors and the agent of any of these, insurance broker, insurance agent or other intermediary, my employer or Financial Ombudsman Service Limited (FOS) for the purposes of administering my claim or providing a report. I understand that a copy of the A.I.S. Insurance Brokers Pty Ltd privacy policy statement, including information about access, may be obtained by downloading a copy from A.I.S. Insurance Brokers Pty Ltd website or calling Signed: X Date Please submit your Claim Form and supporting documents to: A.I.S. Insurance Brokers Pty Ltd 137 Moray Street South Melbourne VIC claims@aisinsurance.com.au Page 3 of 5
4 MORTALITY CLAIMS INFORMATION Situation A: Animal found deceased The A.I.S. Insurance Broker team send you their condolences for your sad loss. We understand this is a difficult time for you, so we have prepared this information sheet to assist as much as possible during this process. Please do not hesitate to contact us if you have any questions. Step 1: Notify the A.I.S. Insurance Brokers Equine & Livestock Team as soon as practically possible: Phone: horse@aisinsurance.com.au If outside business hours of Monday to Friday 8:45am-5:15pm AEDST, please contact Natasha Golden on mobile Step 2: Provide to A.I.S. Insurance Brokers within 60 days: 1. Claim Form completed by you 2. Veterinary report regarding the death and clinical history 3. If the cause of death is unknown, we will require a Post Mortem examination and report to be conducted by a veterinarian To: claims@aisinsurance.com.au Fax: Step 3: A.I.S. Insurance Brokers Claims Manager and our consulting veterinarian will assess the claim. Step 4: You will be advised of the claim outcome: If declined: You will be provided with the reason for the decision and your rights if not satisfied. If accepted: You will be provided with settlement details and required to complete and return a Release Form to the Claims Manager. Once this has been received the Claims Manager will make a request for settlement with Finance and settlement will then be arranged to your nominated bank account. Page 4 of 5
5 MORTALITY CLAIMS INFORMATION Situation B: Animal euthanised under veterinary advice The A.I.S. Insurance Broker team send you their condolences for your sad loss. We understand this is a difficult time for you, so we have prepared these information sheets to assist as much as possible during this process. Please do not hesitate to contact Natasha Golden or Emily Brewer if you have any questions. Step 1: Notify the A.I.S. Insurance Brokers Equine Team as soon as practically possible that euthanasia on humane grounds has been prescribed by a veterinarian as the only treatment option: Phone: horse@aisinsurance.com.au If outside business hours of Monday to Friday 8:45am-5:15pm AEDST, please contact Natasha Golden on mobile Step 2: Provide to A.I.S. Insurance Brokers within 60 days: 1. Claim Form completed by you 2. Veterinary report and clinical history 3. Euthanasia Certificate To: claims@aisinsurance.com.au Fax: Step 3: A.I.S. Insurance Brokers Claims Manager and our consulting veterinarian will assess the claim. Step 4: You will be advised of the claim outcome: If declined: You will be provided with the reason for the decision and your rights if not satisfied. If accepted: You will be provided with settlement details and required to complete and return a Release Form to the Claims Manager. Once this has been received the Claims Manager will make a request for settlement with Finance and settlement will then be arranged to your nominated bank account. Page 5 of 5
EQUINE & LIVESTOCK INSURANCE CLAIM FORM
EQUINE & LIVESTOCK INSURANCE CLAIM FORM The provision of this form by A.I.S. Insurance Brokers Pty Ltd is not an admission of liability or acceptance by A.I.S. Insurance Brokers Pty Ltd of your claim.
IF THERE IS INSUFFICIENT SPACE ON THIS FORM TO PROVIDE FULL DETAILS, ATTACH A SEPARATE SHEET.
IT IS EXPRESSLY UNDERSTOOD AND AGREED THAT THE FURNISHING OF THIS BLANK FORM TO THE ASSURED OR THE ASSISTANCE OF ANY ADJUSTERS OR ANY AGENT OF THE INSURER IN THE MAKING OF THIS PROOF IS NOT A WAIVER OF
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