Important:

We are unable to process claims where the claim form is incomplete. All relevant sections must be completed to avoid delay.

Our Commitment to You:

We are totally committed to providing a fair and prompt claim settlement service to you. As soon as we have the completed information before us, we will issue a Claims Advice to you within a matter of days and then arrange for the dispatch of the Insurer's claim cheque within 5 working days in most cases.

Should you have a complaint about our service or claim settlement procedures, please notify us so that we can immediately address your concerns. In the first instance your complaint should be faxed to Sharon Fox-Slater (Claims Manager) on 1300 794 773 or emailed to sharonfs@ebminsurance.com.au.

Policy Details
Policy Number: Insured Property (Address): * Landlord's Name: * Is your property owned by a business/company? * No   Yes Business/Company name: Is the landlord registered for GST? No   Yes ABN Number: Have you claimed or intend to claim an input tax credit on the GST component of the premium applicable to the Policy? Will you be claiming an amount less than 100%? No   Yes Specify amount claimed: Are you entitled to claim an input tax credit for repairs or replacement of the item that has been lost of damaged: - Will you be claiming an amount less than 100%? No   Yes Specify amount claimed:
Contact Details
Person submitting claim: * Phone number: * Agent's Name: (If your Agent has changed since cover was effected and your policy details have not been updated, please advise previous Agent's name) Agent's e-mail address: Agent's Phone number: Agent's Facsimile: Please advise the payee name to be shown on the cheque payment: * Please advise the address where correspondence and the claim payment cheque should be sent: *
Are you claiming for Loss of Rent?	No Yes
The following documents are required to process your claim. Please confirm how we will receive these: * Documents are attached Document Add another document. Documents will be faxed to 1300 794 773 Attention: Claims Department Please note policy number on faxed material. Documents will be mailed to Suite 4, 651 Victoria Street, Abbotsford Vic 3067 Attention: Claims Department Please note policy number on mailed material (mailing document copies may slow the processing of your claim) All Loss of Rent claims (please tick to confirm) Original Bond Deduction Invoices Copy of the Tenancy Application Tenant Rental History Printout Copy of Breach or Termination Notices Copy of front of the Tenancy Agreement that shows names, dates, rent, bond details etc and also a copy of any special conditions Copy of court documents (if applicable), copy of other legal documents or receipts etc. issued by either party Copy of Bond Lodgment Form If any items are missing please provide the reason and state when you believe they will be available: Tenancy Details Names on Tenancy Agreement: * Dates on Tenancy Agreement: * to Weekly Rent: * Bond: * It is a requirement of the policy that the bond be equivalent to at least 4 weeks rental value. If the bond does not meet this requirement provide details as to why: Statement of what happened: * Date Problem Detected * Date Tenant Vacated Property * Date Rent Paid to (excluding Bond) * Total Rent Loss * From: To: Claimed Rent Loss * From: To: Is there a new Tenant? * Yes No If Yes, date new tenant commenced: If No, why not?: Important Notes Regarding Damage 1. We DO NOT authorise repairs. It is up to the insured to take all necessary steps to minimise a claim under the policy. 2. Items normally covered under a Householder's policy are NOT CLAIMABLE under section 3 (e.g. Glass breakage, fusion, fire, storm and water damage). For a defined event claim (such as these) please complete section 4. 3. The following costs are NOT CLAIMABLE as damage but are costs which may be deducted from the bond: Clean up (e.g. Carpet cleaning, lawns and gardens, rubbish removal, accumulation of dirt and minor damage over the tenancy) Re-letting fee or part thereof (where payable under a fixed term lease) General repairs and tenant neglect
Are you claiming for damage or theft by the tenant?	No Yes
The following documents are required to process your claim (if they have been attached in a previous section they do not need to be attached again). Please confirm how we will receive these: * Documents are attached Document Add another document. Documents will be faxed to 1300 794 773 Attention: Claims Department Please note policy number on faxed material. Documents will be mailed to Suite 4, 651 Victoria Street, Abbotsford Vic 3067 Attention: Claims Department Please note policy number on mailed material (mailing document copies may slow the processing of your claim) All Damage/Theft By Tenant Claims (Please Tick To Confirm) Original Bond Deduction Invoices Copy of Bond Lodgment Form Tenant Rental History Printout Copy of the Tenancy Application Copies of ingoing and outgoing inspection reports Copy of Police Report (Malicious Damage and/or Theft by tenant claims only) Copy of court documents (if applicable), copy of other legal documents or receipts etc. issued by either party Copy of front of the Tenancy Agreement that shows names, dates, rent, bond details etc and also a copy of any special conditions Original quotes and/or invoices for repairs (note: if repairs are over $500 - 2 quotes are required) If any items are missing provide the reason and state when you believe they will be available: Date of Event * Was the damage/theft reported to the police? *   Yes   No If yes, Date Reported Police Station / Officer Police Report Number Name and address of Witnesses (if any) 1) Bond Disbursement (note - claimable damage should be detailed in part 2 below) Note: Clean up and allowable costs that exceed the bond are not claimable and all claims are subject to policy limits. Clean up and other allowable costs (please list) (Detailed Original Tax Invoices must be provided) Total Costs / Expenses Are Legal Expenses being claimed? * Yes   No If Yes, how much? Are you claiming for the cost of changing locks following bailiff eviction? * Yes   No 2) Damage and/or Theft By The Tenant Has Malicious Damage or Theft by the Tenant occurred which exceeds the excess of $400 per claim? * Yes   No Has Accidental Damage occurred which exceeds the excess of $400 each event? * Yes   No Statement of how you believe the Damage or Theft by the Tenant occurred: Repair Costs (please detail) If the premises (or part of) are being re-carpeted, we need to know when the property was last carpeted: Age of carpet Condition Replacement Cost If the premises (or part thereof) are being painted, we need to know when the property was last painted Note: Any depreciation to carpet or maintenance deductions on painting are generally deducted at the rate of 7.5% per year.
Are you claiming for damage or theft NOT by the tenant?	No Yes
The following documents are required to process your claim (if they have been attached in a previous section they do not need to be attached again). Please confirm how we will receive these: * Documents are attached Document Add another document. Documents will be faxed to 1300 794 773 Attention: Claims Department Please note policy number on faxed material. Documents will be mailed to Suite 4, 651 Victoria Street, Abbotsford Vic 3067 Attention: Claims Department Please note policy number on mailed material (mailing document copies may slow the processing of your claim) All damage/theft claims not by tenant (please tick to confirm) Original quotes and/or invoices for repairs (note: if repairs are over $500 - 2 quotes are required) Copy of Police Report (Malicious Damage and Theft by an intruder claims only) If any items are missing provide the reason and state when you believe they will be available: Date of Event: * Time of Event: * Was the damage/theft reported to the police? *   Yes   No If yes, Date Reported Police Station / Officer Police Report Number Name and address of Witnesses (if any) Detailed Description (including cause of damage) * Who caused the loss/damage (include name and address if known) * If claiming for loss by Burglary or Theft, describe method of entry * Particulars of claim (please detail)
Declaration
BEFORE AGREEING TO THE DECLARATION BELOW Have you completed ALL REQUIRED SECTIONS of the claim form? We are unable to process claims where the claim form is incomplete. Declaration I/we do hereby declare that to the best of my/our knowledge the foregoing answers are true and correct and I/we have in no manner caused the said loss or by any fraud or willful misrepresentation sought unjustly to benefit by the said event and that the information detailed in the claim form above is a true and faithful account of the actual loss sustained excluding any profit or advantage. No information likely to affect this claim has been withheld. And I/we hereby undertake and agree to notify EBM immediately if any of the property mentioned in this claim is subsequently recovered, and at the option of EBM to return the property or to refund the amount of money received by way of compensation in respect thereof. I agree that the statements made above are true and correct Your Name *   Date: 8/09/2010 It is always hoped that tenants can be pursued in an attempt to recover claim settlement money, in the long term this can help to keep premiums to a minimum. Should you have any knowledge as to the current whereabouts of the tenant, their place of work, or any other information you believe may assist, please detail it below. Tenant's forwarding address (if known): Tenant's last known address: Tenant's last known place of work: Any additional information