Breakdown Insurance Claim Form

Submit your claim

Page: Claims - Breakdown

"*" indicates required fields

Comments

This field is for validation purposes and should be left unchanged.

Please fill in the details below as accurately as possible to help us progress your claim

Name of Insured*

Email*

Phone*

Insurance Product*

Address*

Policy number*

Date of loss*

Location of loss*

Describe as fully as possible how the loss occurred*

Is the machinery / appliance under manufacturer's warranty? If YES, has a claim been made under the warranty?*

Machinery

Make of motor*

Machinery serial number*

Voltage*

Electronic item

Electronic item serial number*

Electronic item age*

Details and cause of damage/breakdown

Description of goods*

Quantity (optional)

Total Sum claimed*

Insurance history

Have you had any claims in the last 5 years? (YES / NO If Yes, provide details.)*

Has any Insurance Company refused to renew or cancelled/terminated a policy? Has any Insurance Company refused a claim? (YES / NO If Yes, provide details.)*

Have you been convicted of or had any fines or penalties imposed for any criminal offences in the last 10 years? (YES / NO If Yes, provide details.)*

Additional Information (optional)

Do you have a supporting quote, invoices or photo’s that will assist us to lodge your claim with your insurer? (If yes – please email these to claims@bruce.com.au).