Make a Claim

Property Claim Notification Form

Simply fill out the claim notification form below and one of our claims specialists will be in contact with you shortly.

Fields marked with an * are required.

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About Your Claim

We will contact you as quickly as possible about your claim.

For many claims the insurer will check the circumstances and damage before they authorise and pay for repairs.

The insurer may appoint a loss adjuster or investigator or contact you for more information.

Do not authorise repairs yourself

If possible, retain any damaged items, as the insurer may need to inspect them before settling your claim.

If possible, please attach proof of purchase, for each item being claimed e.g. receipt, invoice, bank/credit card statement, photo of the items, manual etc.

Important Information

The information requested and documents mentioned in this form are a general guide. Further documents or information may be required depending on the circumstances of your claim.

Please note that failure to provide supporting documentation may result in delays in the processing of your claim.

Your Policy may not provide cover under every section shown in this Claim Form. The issuance and acceptance of this form does NOT constitute an admission of liability by the insurer or waiver of its rights.

If you have any questions about your claim, please contact Clearlake Insurance Brokers on:

02 9037 8970

info@clearlakeinsurance.com.au

If You Are Submitting Via Phone

"*" indicates required fields

X/Twitter

This field is for validation purposes and should be left unchanged.

Section A:

Particulars of Policyholder/Insured Person

Name of Policyholder/Insured Person (As shown in NRIC/Passport):*

First Middle (If required) Last

Address of Policyholder/Insured Person:*

Street Address Address Line 2 City State Post Code

Policy Number:

Tel Number:*

Email:*

Enter Email Confirm Email

Section B:

Payment Details

Please provide details for payment of your claim in the event that the claim is deemed payable by Clearlake.

I hereby authorise and request Clearlake to pay benefit due in respect of this claim as follows:

EFT

Electronic Funds Transfer (For payments in SGD and to bank accounts in Singapore)

Name of Bank:

Payee Name (As per bank account name):

Branch Code Number:

Account Number:

Note: For a more seamless experience, we recommend selecting the Electronic Funds Transfer (EFT) option so you can receive the remittance within 3-5 days upon approval of claim.

Cheque

Cheque Payment (Not recommended)

Payee Name (As per bank account name):

Important Notice:
Clearlake shall (i) be discharged from all liability under this claim and (ii) not be liable for any and all losses incurred by you, as a result of you providing Clearlake with an incorrect bank account number under this section for the payment of this claim.

Section C:

Details of Loss/Occurrence

Place of loss/occurrence:*

Date of loss/occurrence:*

DD slash MM slash YYYY

Time of loss/occurrence (24-Hour):*

Hours

Minutes

What happened, how did it happen and why? (Please use supplementary sheet if necessary)*

Section D:

Police Report

Please note:

The Police must be informed immediately if the property has been damaged, lost or stolen.
A copy of the Police Report/Statement must be attached in Section G:

Were particulars of loss taken by or reported to the Police?*

Yes

If Yes, please attach a copy of the Police Report/Statement(s) in Section G:

If No, please state reason(s) that the loss was not reported to the Police.

Section E:

Details of Property Destroyed, Damaged and/or Lost

Please note:

Property damaged, lost or stolen are to be described in detail.
Receipts showing date, price/cost, and place of purchase of the article/item set out below should accompany this form.
The Insured must promptly take all possible steps to trace/recover the property lost.
If the claim is for damage, an estimate for repair should be submitted. If the property is not repairable, a letter from repairers to that effect should be forwarded (This may or may not be applicable depending on the terms of your policy. Please read your policy to check the provisions for damaged insured equipment).
All salvage must be retained.
In the case of damaged property, a set of photographs depicting the damage is to be submitted to us.

Details of Property Destroyed, Damaged and/or Lost

Description of property lost or damaged	Quantity	Original purchase price ($)	Date	Value at time of loss after deduction for wear & tear ($)	Amount claimed ($)	Actions

There are no Entries.

Maximum number of entries reached.

Total Amount Claimed

Did you remove or save any property immediately before or during the occurrence?*

Yes

If Yes, how much and where is it located now?

Are you the sole owner of the property/article lost or damaged?*

Yes

If No, please state name, address and relationship of other owner(s).

Section F:

Any Other Insurance

Are there any other policies of insurance in force covering you or the subject matter in respect of this event?*

Yes

Other Insurance

Name and address of insurance company	Policy no.	Actions

There are no Entries.

Maximum number of entries reached.

Are you claiming under any of the policies listed above?*

Yes

Section G:

Declaration

Tick the corresponding boxes, and then attach relevant forms where applicable

Police Report*

Yes

N/A

Attach Police Report(s)

Drop files here or

Max. file size: 16 MB.

Purchase receipts, warranty card and photographs (For loss and/or damage of personal property claim)*

Yes

N/A

Attach Purchase receipts, warranty card and photographs

Drop files here or

Max. file size: 16 MB.

Documents with relevant authorities concerned (For damage of personal property claim)*

Yes

N/A

Attach Documents with relevant authorities concerned

Drop files here or

Max. file size: 16 MB.

Repair quotations or written confirmation issued by the repairer stating property is beyond repair*

Yes

N/A

Attach Repair quotation(s)

Drop files here or

Max. file size: 16 MB.

Relevant receipts (For communication and/or replacement cost)*

Yes

N/A

Attach Relevant receipt(s)

Drop files here or

Max. file size: 16 MB.

Letter from the third party concerned (For Legal Liability claim)*

Yes

N/A

Attach Letter from the third party concerned

Drop files here or

Max. file size: 16 MB.

By signing this form, I agree that Clearlake Insurance Brokers will use the information supplied here and during the formation and performance of the policy, for policy administration, customer services, claims handling and fraud analysis and prevention, and that Clearlake Insurance Brokers may disclose such information to its service providers, agents, authorities and other parties for these purposes.

I authorise any person or entity to provide to Clearlake Insurance Brokers or its authorised representatives, any and all information with respect to any loss and claims, police records, investigation status and results, and such personal information as Clearlake Insurance Brokers in its absolute discretion considers relevant for its assessment of this claim. A photostatic copy of this authorisation shall be considered as effective and valid as the original.

I do solemnly and sincerely declare that the foregoing particulars are true and correct in every detail and I agree that if I have made or in any further declaration or representation shall make any false or fraudulent statements or suppress, conceal or falsely state any fact whatsoever the Policy shall be void and all rights to recover thereunder in respect of past, present or future claims shall be forfeited.

Signature of Policyholder/Insured Person*

Date (DD/MM/YYYY)*

DD slash MM slash YYYY