Farming All Risk Claims Form

Please fill out the form below to submit a claim.

Policy Number *

Expiry Date *

Insured Name *Company, Partnership, Trust etc

Contact First Name *

Contact Last Name *

Contact Email Address *

Contact Phone Number *Please include area code and phone number

Contact Address *

Street address *

City *

State *

Postcode *

Are you registered for GST purposes? *

YesNo

What is your ABN? *

Have you claimed or do you intend to claim an input tax credit on the GST applicable to this policy? *

YesNo

Percentage of GST Claimed? *%

When did the loss, theft or damage occur? *

Address where loss, theft or damage occurred *

Street address *

City *

State *

Postcode *

If 'Other' please advise on type of loss *

When was the loss, theft or damage discovered? *

Describe what happened *

Date and time the premises was last occupied *

Was the property securely locked? *

YesNo

Does the property have a security alarm? *

YesNo

Was the alarm activated at the time of the incident? *

YesNo

If alarm was not activated, advise why. *

How was entry gained? *

Has the forced entry damage been repaired? *

YesNoNot Applicable

Please upload invoice (if applicable)

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Advise why forced entry damage has not been repaired *

Are any further make-safe or other repairs required to secure the premises? *

YesNo

List any improvements made since the loss

Were there any witnesses to the incident? *

YesNo

List Witness Name(s) and Contact Details *

All burglary/theft/vandalism and claims involving damage caused by a third party must be reported to the Police. We may apply for a copy of the Police Report to verify the claim circumstances.

Was the loss reported to or attended by the Police? *

YesNo

Police Station *

Police Report Reference *

Police Officer *

Date Reported *

Was the loss reported to or attended by the Fire Brigade?

YesNo

Fire Station *

Fire Brigade Reference *

Fire Brigade Officer *

Date Reported *

Please provide a detailed list of the damaged or stolen property

Property/Item (including brand, model if applicable) *

Owner *

Age *

Purchase Cost (if applicable)

GST Applicable? *

YesNo

Claimed Amount *

Are any of these items covered under any other insurance policy? *

YesNo

If yes, please provide more information.

Item *

Type of Insurance *

Insurer *

Policy Number *

Is the property repairable? *

YesNoUnsure

Have you arranged an inspection/quotation(s)? *

YesNo

Please upload quotation(s)

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Do you want Harland Green to assist with the appointment of a repairer/supplier? *

YesNo

Do you have any finance or owe money on any of the damaged or stolen property? *

YesNo

If yes, please provide more information.

Item *

Lender *

Lender Contact (address, email) *

Reference *

Amount Owing *

Upload images of damage or any other relevant files

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Declaration

I declare that the above information is true and correct and I have not withheld any relevant informationrelating to the claim.

First Name *

Last Name *

Date *

Signature *

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Please verify you are a human *

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