Breakdown Insurance Claim Form

Submit your claim

Page: Claims - Breakdown

"*" indicates required fields

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).

Name

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

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