Please complete and submit this form as soon as possible after an incident. Photos are also appreciated. The insurer may require more quotes than stipulated in Council’s Procurement Policy. For example, two quotes may be required if cost of repairs are more than $3,000, and we don’t have a contracted supplier. An Assessor from the insurer may become involved if the cost is more than $5,000.

Please note:
The insurance excess is $1,000 and reimbursements are GST exclusive. This cost is to be borne by the relevant business unit/lessee/responsible third party accordingly. The settlement will be arranged by the Governance Team as soon as reconciled from the insurer.

Claim Reporter

Details of the person that first noticed the theft/damage and reported it:

Name *

Contact Number *

Email *

Date Reported *

Time Reported (if known)

Who at Council did they report it to? *

How was it reported? *

Claim Details

Date of Incident *

Time of Incident (if known)

Please tell us what happened providing as much detail as possible *

What damage, loss or injuries were sustained as a result of the incident? *

Details of type of facility/premises where loss occurred *

Location of Loss *

Was any individual responsible for loss? *

Yes

No

Were there were any witnesses? *

Yes

No

Have Police been notified? *

Yes

No

Is there CCTV footage? *

Yes

No

Approximate cost of repair *

This form was completed by *

Upload Supporting Documents? *

Yes

No

System Information (Internal use only)

CRM/Work Order Number

Asset Number(s)

Account code for reimbursement if claim accepted

Privacy Policy *

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I accept this Privacy Policy

Incident Details for Asset Insurance Claim

Incident Details for Asset Insurance Claim

Claim Reporter

Claim Details

System Information (Internal use only)

Privacy Policy *