Landcover Ref No: 10M 6612460 Need Help with this form ? Call Landcover Support 1300 526 326 Policy number (from your schedule) Expiry date Day Month Year Important noticeNo 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 your insurer for determination. The completion of this form and its receipt by CGU is not an indication that CGU accept any liability to you or to any person claiming from you.Insured’s detailsName of Insured* Your Address Street Address Suburb State Select StateAustralian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia Postcode Address of your vacant land Street Address Suburb State Select StateAustralian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia Postcode Telephone no. Mobile no.* Email Address* Are you registered for GST purposes* Yes No What is your ABN? What was your ‘Entitlement to an Input Tax Credit’ (EITC%) on you’re the amount you paid for this policy Claim detailsDate of incident Day Month Year Time : Hours Minutes AM PM AM/PM Date you first became aware of the incident Day Month Year Has a claim been made on you?* Yes No General informationName and addresses of witnessesFull nameTelephone no.Address Did police, fire brigade, ambulance or other emergency service attend?* Yes No Provide detailsHave there been prior incidents in similar circumstances?* Yes No Provide detailsDo you consider yourself responsible for the accident?* Yes No State reasonName and address of person(s) whom you consider to be responsible and their relationship to you.NameAddress Are you aware of issues with your land that could have given rise to this claim* Yes No Provide detailsInjured person(s) detailsName Address Street Address Suburb State Select StateAustralian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia Postcode Full details of injuriesWhat is your relationship to the person? Property damaged detailsName of the owner(s) of the property damaged Address Street Address Suburb State Select StateAustralian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia Postcode What is your relationship to the owner(s)? Describe the property and the full details of damage (if a vehicle, include make, model and registration)Attach quotations if possible Drop files here or Select files Max. file size: 64 MB. Estimated cost of repair/replacementWas the property in your custody?* Yes No For what purpose?Have any repairs been carried out?* Yes No Name of Repairer Address Street Address Suburb State Select StateAustralian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia Postcode Cost of repairsDeclarationI/We declare that the said loss occurred without my/our knowledge or consent and that I/We have not sought to benefit unjustly from this claim by fraud, wilful misrepresentation or exaggeration. I/We declare that the information supplied on this claim form is true in every respect. I/we agree that, by submitting this form, the personal information I/we provide to CGU Insurance in this form or otherwise may be collected, held, used and disclosed in the manner set out in the CGU Privacy Policy found at www.cgu.com.au/privacy, including for processing this claim. Please attach your LANDCOVER POLICY SCHEDULE any other documents and photos Drop files here or Select files Max. file size: 64 MB. Signature*Print Name* Date Day Month Year
