(a) Are you registered for GST Purposes? Yes No

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1 PROPERTY Commercial Claim - Report Form IMPORTANT INFORMATION Please ensure this Form is completed in all Parts applicable to your claim. The Privacy Consent on the back, must be completed for all claims. Supporting documentation required is detailed below. The issue and acceptance of this Form does not constitute an admission of liability by the Company or a waiver of its rights. SECTION 1 - Insurance and Policy Details Insured (Surname, Company or Partnership) Policy Number Address Telephone (home) Telephone (business) Mobile Situation of Insured Property Body Corporate Managing Agent s Details Phone Broker Details Phone SECTION 2 - Electronic Funds Transfer Details Following ACE approval of your claim, should you wish to have your claim benefits transferred directly into your bank account, please provide the following details: of Financial Institutions: Account : BSB Number: Account Number: SECTION 3 - GST Information (For Australian Claims Only) (a) Are you registered for GST Purposes? Yes No (b) What is your Australian Business Number (ABN)? (c) Have you claimed or are you entitled to claim an Input Tax Credit (ITC) in respect to the GST paid on the insurance policy under which this claim is being made? Yes No (d) IF YES, what percentage of the GST did you claim or are you entitled to claim? (if the GST paid and your ITC entitlement are the same amount, the answer to this question is 100%) % ACE Insurance Limited Contact us The ACE Building 28 O Connell Street Sydney NSW 2000 Australia GPO Box 4065 Sydney NSW 2001 Australia main fax Page 1 of 5

2 SECTION 4 - Claim Details When did the loss, theft, damage happen? : / / Time: Please tell us what happened? Was the loss reported to the police? (The police MUST be notified when property is lost, stolen or maliciously damaged) Yes No Police Station Incident No: Reported: / / If your property was lost, stolen or maliciously damaged, do you know who is responsible? Yes No IF YES, please provide details Were there any witnesses to the loss, theft or damage? Yes No IF YES, please provide details Who discovered the loss, theft or damage? Discovered List of Article(s) Lost, Stolen or Damaged Full description of each item lost, stolen or damaged of Purchase Original purchase price ($) Input tax credit you can claim on the purchase of these items as a % of the total GST payable ( * Only complete this column if the items being claimed for are used in connection with your GST registered business) Replacement price/amount being claimed ($) Plumbing Repairs - where applicable If your plumber has not already done so, please ensure the following information is provided on the account/invoice: - Nature and cause of leak - Composition of pipe (i.e. gal, copper, PVC, etc.) - Procedures undertaken - Details of charges including, hourly rate, number of persons on the job (if more than one, please explain the necessity for additional person and details of costs) - Apportioned repair cost between: (a) search & find (b) plumbing repair (c) reinstatement Electrical Damage (Fusion) - where applicable For Fusion claims please complete the Fusion section at the back of this form. Is the Property repairable? Yes No IF YES, attach a quote for the repairs IF NO, attach original receipts, valuations, quote for replacement or a certification from an authorised repairer that the item is unrepairable. Page 2 of 5

3 SECTION 4 - Claim Details (continued) Do you owe money on the property lost, stolen or damaged? Yes No Lender s name Approx amount owing $ Address Postcode Some of the property lost, stolen or damaged may be covered under other policies, including health insurance. Please list any other insurance you have which might cover these items. of insurer Policy No. Type of Insurance SECTION 5 - Fusion Claim Form and type of Appliance Horsepower of Machine of Purchase / / Is it under guarantee? Yes No If a Motor, or Controlling Device, state purpose for which Motor is used Nature of Loss or Damage Cause of Loss or Damage If, in your opinion, the Loss or Damage was caused by the negligence of anyone, state by whose negligence it was caused Estimated Cost of Repairs $ Is the property under Hire Purchase? Yes No IF YES, which company? Is the property on loan to you? Yes No IF YES, by whom? Was the property otherwise insured? Yes No IF YES, state name of company? Signature of Insured: / / NOTE: The report overleaf must be completed and signed by the electrical repairer. SECTION 6 - Electrical Damage (Fusion) - Repairer s Report (to be completed by the Repairer) of customer Make of motor Horsepower Serial No. Type of appliance Brand Age Details of damage Cause of damage Page 3 of 5

4 SECTION 6 - Electrical Damage (Fusion) - Repairer s Report (to be completed by the Repairer) continued DETAILS OF REPAIRS AND SERVICE CHARGES Please indicate (yes/no) whether destruction or damage to any part or parts of the electrical machines, installations or apparatus was caused by the actual burning out of such part or parts by the electric current therein. N.B. Open circuits, worn or damaged bearings or any other mechanical faults are not covered by this insurance. MOTOR REPAIRS (NOT SEALED UNITS) Windings of Stator Yes No Windings or Rotor or Armature Yes No Brushes Yes No Bearings (give details and reason for same) Yes No SWITCH GEAR SEALED UNITS (i) Motor Repairs Yes No (ii) Compressor Repairs Yes No (iii) If replacement unit fitted state allowance on old unit Yes No AUXILIARY FAN Yes No ELECTRICAL CONTROLS Yes No FLUSHING AND RECHARGING WITH REFRIGERANT Yes No AUXILIARY EQUIPMENT Yes No OTHER REPAIRS Yes No REMOVAL AND REINSTALLATION Yes No HIRE OF LOAN MOTOR INCLUDING INSTALLATION AND REMOVAL Yes No DETAILS OF OVERTIME COSTS Yes No TRANSPORT COSTS Yes No $ TOTAL $ Signature of Repairer: / / Electrician s Licence No. Page 4 of 5

5 ACE Insurance Limited Claim Privacy Consent, Authority and Declaration CLAIM PRIVACY CONSENT ACE Insurance Limited (ACE) is committed to protecting your privacy. ACE collects, uses and handles your personal information only in accordance with the Privacy Act 1998 (Cth) (Privacy Act). A copy of our Privacy Policy is available on our website at or by contacting our customer relations team on Your personal information will be used by ACE, or any third party that ACE provides the information to, for the purpose of assessing your claim or your entitlement to benefits and, if the claim is accepted, for administration of the claim and for planning, product development and research purposes. Your personal information may include: (a) any information provided in relation to your claim; (b) any information that is health information or sensitive information, including, without limitation, your medical history, any treatment received by you and any medication taken or prescribed for you (at any time) or your Health Insurance claims history, including Medicare; (c) any other personal information that you may provide to ACE or its third party contractors; (d) any information relating to any insurance policy on your life, including terms and conditions and claims history; (e) details of your employment including position, period of employment, remuneration, hours worked and duties performed (at any time); and (f) any other information relating to your income, assets, liabilities and solvency; and (g) any information from third persons who may have information relevant to your eligibility to receive a benefit, or your entitlement to receive an ongoing benefit. To assess and process your claim ACE may need to collect your personal information from third parties such as your insurance broker, claims reference services, government organisations (for example, social security agencies or taxation offices), your doctor or other health service provider, any forensic accountant or investigator retained by ACE, your employers (past and present), your accountant and any businesses which provide information about the commercial activities of persons or, if you are, or have been, bankrupt the trustee of your estate (the Parties ). ACE may disclose your personal information, including health and sensitive information, to other entities within the ACE Group, other insurers, our reinsurers or third parties, including contractors and contracted service providers (such as assessors or investigators) who we, or those other ACE Group entities, have engaged to provide a specific service. Those entities may be located overseas, for example the regional head offices of ACE in Singapore, UK or USA or in the Philippines where certain business process functions of ACE are performed by a dedicated servicing unit. ACE may also disclose your personal information to witnesses in respect to your claim and to government agencies including the police (where we are compelled to by law). If you do not consent to the terms of this Privacy Consent and Medical Authority or revoke your consent, ACE may not be able to process or assess your claim. If you would like to access a copy of your personal information, or to correct or update your personal information, please contact our customer relations team on or AUTHORITY AND DECLARATION I understand that by investigating my claim or by accepting proofs of my claim, ACE has made no acceptance of liability, nor waived any of its rights in defence of any claim arising under the policy. I agree to ACE using and disclosing my personal information pursuant to ACE s Privacy Policy and this document. In the event of any conflict between the documents, this document will be determinative. This consent remains valid unless I alter or revoke it by giving written notice to ACE s privacy officer. I authorise any person or entity, including but not limited to the Parties referred to above, to provide to ACE such personal information (including health information) as ACE in its absolute discretion considers relevant for its assessment of my claim or my entitlement to benefits. I will use my best endeavours and render all reasonable assistance and co-operation to ACE in the assessment of my claim. I confirm that any information that I supply will be true and correct and that I will not withhold any information likely to affect the acceptance or handling of my claim. I understand that my claim may be denied if the information supplied is untrue, or I have not revealed all relevant facts. I appoint ACE to do everything necessary or expedient to give effect to the transactions contemplated by the consents and authorisations in this document and to execute, on my behalf, any documents or to do such acts required to give effect to this Privacy Consent and Medical Authority. Signature of claimant of claimant Signature of claimant of claimant ACE Insurance Limited ABN AFSL The ACE Building, 28 O Connell Street Sydney NSW Phone: Fax: ACE Group. Coverages underwritten by one or more companies of the ACE Group. Not all coverages available in all jurisdictions. ACE, ACE logo, and ACE insured are trademarks of ACE Limited. ACE Page 5 of 5

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