Elkington Bishop Molineaux Insurance Brokers Pty Ltd | ABN 31 009 179 640 | AFSLN 246986 | Est 1975 Musical Instruments Claim Form | Page 1 of 2

Please complete the form and choose either EMAIL THIS FORM to email the form or PRINT THIS FORM to print then fax or post

MUSICAL INSTRUMENTS CLAIM FORMPost to: Musical Instruments Division Fax: 1300 365 822 EBMPO Box 10841, Southport BC Qld 4215

IT IS A CONDITION OF YOUR POLICY THAT WRITTEN DETAILS OF THE CLAIM ARE RECEIVED BY INSURERS WITHIN 30 DAYS. PLEASE RETURN YOUR CLAIM FORM AS SOON AS POSSIBLE.

1.0 Contact Details

Mobile: Fax:

State: Postcode:

Email:

Phone:

Suburb:

Instructions:

Privacy - We are committed to protecting your privacy. We use the information you provide to advise about and assist with your insurance. We only provide your information to insurance companies, underwriting agencies, wholesale brokers and premium funders with whom you choose to deal (and their representatives). We do not trade, rent or sell your information. If you don’t provide us with full information, we can’t properly advise you and you could breach your duty of disclosure. You can check the information we hold about you at any time. For more information about our Privacy Policy, ask us for a copy or visit our website www.ebm.com.au. By completing the form below, I certify that I am aware that any collection of personal information is used in accordance with EBM’s Privacy Policy.

The issue of this Form is not an admission of liability and is issued without prejudice.

BEFORE ANY QUESTIONS ARE ANSWERED, PLEASE READ CAREFULLY THE DECLARATION AT THE END OF THIS FORM WHICH YOU ARE REQUIRED TO SIGN.

Name:

2.0 Claim Information

Are you the Owner of the property insured?

Describe how the loss/damage occured?

Description of Property lost or damaged:

NoYes

Address:

Elkington Bishop Molineaux Insurance Brokers Pty Ltd | ABN 31 009 179 640 | AFSLN 246986 | Est 1975 Musical Instruments Claim Form | Page 2 of 2

CLEAR FORM to start over PRINT this form to Post or FaxEMAIL to EBM SAVE

If any other action has been taken to recover the property, please give details:

Name of Repairer:

Address of Repairer:

PAYMENT OF YOUR CLAIM (Please tick which method you would prefer):

To your repairer directly (Details above) To your Bank Account directly

Bank & Branch:

3.0

Have the Police been notified? No

Report/Reference Numbers:

If Yes, please complete the below information;

Account Name:

BSB Number: Account Number: Swift Code:

I hereby declare that the details given on this form are complete and true to the best of my knowledge.

Declaration

IF THEFT, MALICIOUS DAMAGE OR LOSS IS INVOLVED, THE POLICE MUST BE NOTIFIED

PROMPTLY.

Date of Loss/Damage: Time of Loss/Damage:

Yes

2.0 Claim Information (Continued)

Date of Notification:

Station:

If damaged, what is the estimated cost of the repair? (Please attach a quote)

PLEASE NOTE: No repairs are to be undertaken without express approval from EBM.

EBGE

A408

0-180706

Signature: Date:

Please return to EBM with copy of the quote for repairs, your valuation and photos of damage.