The issue of this form is not to be taken as an admission of liability by the Insurers. It is important that a complete answer be given to every question. If insufficient space is provided for your answers, please attach a separate sheet. Fire and GA Claims Department - Fax: 6225 9887
Name of Policyholder
Policy No
Tel No
Contact Person
Residential Address
Business Address
Office No

State fully what happened
Place of occurrence
Nature of loss or damage
Who discover this loss/damage?
Date discovered
Do you know who cause this damage?
Please state name and address of this person
The Police must be informed immediately if the property has been lost, stolen or maliciously damaged. Please attach a copy of police report if applicable.
Name of police station report was lodged
Were the premises occupied at the time of the loss?
by whom
If entry was illegal, how and between what hours it happened?
State if rooms were ransacked.
Please give details
1 2 3 4
Quantity Description Date Acquired Cost Price
5 6 7 8
Value at time of loss (Replacement Cost, if Building) Amount of damage sustained Value of salvage Net amount of claim ie difference between amounts in (6) & (7)
What is the total value at the time of
the loss of all the property insured by this policy?
Do you own the property?
Is the property subject to a hire purchase or loan agreement?
Please give name of the finance
or lending company, their address and agreement number
Was the property on loan or hire to another party?
Please give name and address of party
Is any other party interested in the property?
Please give name of party and extent of
Is there any other insurance on the property?
Please provide details as follows:
Company Policy No Sum If interest covered is different from that covered by our policy, give details
Have you ever before sustained loss of this nature?
Please give details
Have you ever made a claim of this
nature on us or on any other insurer or underwriter?
If Yes, give details

Declaration: I/We hereby declare that these particulars are true to the best of my/our knowledge and belief and I/we have in no manner caused the loss nor by any fraud or misrepresentation sought to benefit thereby. I/We accept that insurers would be at liberty to deny liability in part or in full if the above written answers are false or inaccurate in any aspect

Please note that all personal information provided to TMiS is subject to the Personal Data Protection Policy Statement posted at under privacy statement.
  1. Wherever possible, claims should be accompanied by Builders', Architects' or Repairers' estimates.
  2. A Fire Policy being a contract of Indemnity only, no profit or any kind should be included in the amount claimed.
    • Claims in respect of Building should be based upon the cost of restoring them to the condition they were in at the time of the loss. Contemplated improvements must not be included.
    • Claims for Furniture, Fittings, Machinery, Tools, Electrical Appliances, etc., must not exceed their value at the time of the loss; that is, after due allowance has been made for age, wear and tear and depreciation during the time they have been in use. Where appropriate, the claim will be based on the cost of repairs or of restoration.
    • Claims for Stock-in-Trade should be based on values at the time of the loss after deduction of all discounts or allowances. Due allowance must be made for out of date and unsaleable stock