Important notice each incident requires a separate claim form. Postal Address Risk/Cost Centre

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1 Travel Claim Form 221 St George s Terrace, Perth GPO Box K837 Perth WA 6842 Telephone (08) Facsimile (08) Website Important notice each incident requires a separate claim form THE FOLLOWING GUIDE IS TO ASSIST YOU IN COMPLETING THIS CLAIM FORM Type of Claim Sections to complete Personal Accident/Medical Expenses 1, 2, 3, 4 and 10 Baggage 1, 2, 3, 5 and 10 Additional Expenses 1,2, 3, 6 and 10 Money/Documents 1,2, 3, 7 and 10 Loss of Deposit/Cancellation 1, 2, 3, 8 and 10 Personal Liability 1, 2, 3, 9 and AGENCY DETAILS Agency Name Postal Address Risk/Cost Centre Phone Fax 2. CLAIMANT AND GENERAL DETAILS Family Name Given Name Date of Birth / / Phone Address Suburb/Town 1. Person s relationship to the Agency (e.g. Employee, etc) 2. Did the claim occur during an authorised business trip for the Agency? Yes No If No, give details 3. Advise details of journey: Departure Date / / From: To: Return Date / / 4. Date of incident / / Time am/pm 5. When was the incident discovered? (if appropriate) / / 6. Where did the incident occur? 7. Describe the nature of the claim: Form 469/7/07 Page 1

2 8. Is there any other insurance covering any part of the claim? Yes No If Yes, advise nature of policy, name of Insurance Company and Policy No. 9. Have you claimed for any benefit or refund or are you entitled to claim from any source whatsoever (including any private health insurance fund, insurance company, Medicare or Workers Compensation Act) in respect of this incident (including medical expenses)? Yes No If Yes, advise details and amounts of such benefits or refunds 3. WITNESS DETAILS (if applicable) Name Address Daytime Contact Number 4. PERSONAL ACCIDENT/MEDICAL EXPENSES Note: Medical, Additional out of pocket Expenses and Loss of Deposits claims first obtain the refunds from Medicare and/or Private Health Fund (if any), then enclose all relevant medical certificates or death certificate, accounts, receipts, documents and statement of benefit from Medicare and/or Private Health Fund to support the claim. 10. How long has the person been confined to: Bed: From / / to / / House: From / / to / / Hospital: From / / to / / 11. Advise name and address of doctor(s) attending the person 12. If admitted to Hospital, advise name of the Hospital 13. Are you a member of a private health insurance fund? Yes No If Yes, advise the name of Fund and the policy number 14. Advise the name and address of your usual Medical Practitioner: 15. Advise details of amounts claimed: NET AMOUNT CLAIMED Form 469/7/07 Page 2

3 5. BAGGAGE Note: Attach invoices, valuations or receipts to support the value of the items being claimed and acknowledgement or documents issued by the Police, Hotel, Carrier or other Authority supporting the notification of the loss. 16. Was the property lost or damaged wholly owned by you? Yes No If No, advise details of ownership 17. Was the loss or damage reported to the police, airline, carrier, hotel or other authority? Yes No If Yes, advise to whom and date reported 18. Has any of the property been recovered or has any arrest been made? Yes No If Yes, give details 19. (a) If you consider any party or person(s) responsible for the loss or damage, provide their name(s) and address(es). (b) Have you lodged a claim or complaint against the responsible party? Yes No If Yes, give details and attach copies of correspondence. 20. Have any arrangements been made for replacement of or repairs to the property? Yes No If Yes, give details 21. Schedule of property lost or damaged Items Lost or Damaged Quantity Date of Purchase Total Replacement Cost Price Value of Salvage (if any) RiskCover Use Only Depreciation where applicable Amount payable A$ Total Amount Payable Form 469/7/07 Page 3

4 6. ADDITIONAL ACCOMMODATION AND/OR TRAVEL EXPENSES 22. Advise details of additional expenses incurred by you: NET AMOUNT CLAIMED 7. MONEY/DOCUMENTS Note: Attach acknowledgement or documents issued by the Police, Hotel, Carrier or other Authority supporting the notification of the loss. 23. Was the money/documentation which was lost or damaged wholly owned by you (e.g. credit card, cheques, travel documents etc)? Yes No If No, advise details of ownership 24. Was the loss reported to the police, airline, carrier, hotel or other authority? Yes No If Yes, advise to whom and date reported 25. Has any of the property been recovered or has any arrest been made? Yes No If Yes, give details 26. Advise details of the loss or damage and amount of claim: AMOUNT CLAIMED Form 469/7/07 Page 4

5 8. LOSS OF DEPOSIT/CANCELLATION Note: Written confirmation of the amount lost must be obtained from the travel agent, transportation company and/or accommodation provider. 27. What date did you advise the travel agent, transport and/or accommodation provider? / / Please advise the company name, address, contact name and telephone number 28. Were any alternative arrangements offered or made? Yes No If Yes, advise details 29. Have you applied for a refund of fares or bookings made? Yes No If Yes, advise amount of refund If No, advise reason 30. Advise details of claim: Amount of deposit paid and date paid / / Balance of costs and date paid / / PAID Less refund received on cancellation NET AMOUNT CLAIMED 9. PERSONAL LIABILITY Note: Attach all letters or claim demands made against you. No admission of liability, either implied or expressed, should be made. Any claim made upon you should simply be acknowledged with advice that the matter has been referred to RiskCover for determination. 31. Provide details of the person making the claim against you including name, address and daytime contact number: 10. DECLARATION I declare that the details submitted are true and correct and that I am the person authorised to lodge the claim against RiskCover on behalf of the above-mentioned Agency. Signature of person having authority Name Phone Title Date / / Form 469/7/07 Page 5

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