Purchase Cover
Claim form
(Office use only)
Please ensure you provide the following information and documentation.
If you don’t provide what is required your claim may be delayed or not paid:
– your monthly credit card statement showing the following:
• accountholder’s full name and address (i.e. statement’s front page)
• purchase of the item being subject to this claim
– purchase receipt,
– if you have additional insurance for this item, a letter from this insurer advising their liability for the subject loss/damage
If Items Damaged
– you need to have the item examined by its manufacturer’s authorised service agent, who is to prepare a report stating:
• the item’s make and model number,
• description of the damage and the cause of the damage,
• quote to repair the damage.
If Items lost/Stolen
– police report, or report number if hard copy not issued,
– letter from the relevant authority stating that the loss was reported to them.
Privacy
Zurich is bound by the Privacy Act 1988 (Cth). Before providing us with any Personal or Sensitive Information (‘Information’), you should
know that:
We collect, use, process and store Personal Information and, in some cases, Sensitive Information about you such as health information, in
order to comply with our legal obligations, assess your application and, if your application is successful, to administer the products or services
provided to you, to enhance customer service and product options and manage a claim (‘purposes’).
If you do not agree to provide us with the Information, we may not be able to process your application, administer your policy or assess your claims.
By providing us or your intermediary with your Information, you consent to our use of this Information and where relevant for the purposes,
you consent to our disclosure of your Personal Information, including your Sensitive Information, to your intermediary, affiliates of the
Zurich Insurance Group Ltd, other insurers and reinsurers, our service providers, our business partners, medical and health practitioners, your
employer, policy owners, government offices and agencies, regulators, law enforcement bodies, and as required by law within Australia or
overseas. These laws include the Anti-Money Laundering and Counter-Terrorism Financing Act 2006, Personal Property Securities Act 2009,
Corporations Act 2001, Insurance Contracts Act 1984, Autonomous Sanctions Act 2011, Income Tax Assessment Act 1997, Income Tax
Assessment Act 1936, Income Tax Regulations 1936, Tax Administration Act 1953, Tax Administration Regulations 1976, A new Tax System
(Goods and Services Tax) Act 1999 and the Australian Securities and Investments Commission Act 2001 as those laws are amended, and
includes any associated regulations. From time to time other acts may require, or authorise us to collect your personal information.
Zurich may obtain Information from government offices, the parties listed above and third parties to assess applications, administer policies
and assess a claim in the event of loss or damage.
For further information about Zurich’s Privacy Policy, a list of service providers and business partners that we may disclose your Information to, a list
of countries in which recipients of your Information are likely to be located, details of how you can access or correct the Information we hold about
you or make a complaint, please refer to the Privacy link on our homepage – www.zurich.com.au, contact us by telephone on 132 687, by email at
privacy.officer@zurich.com.au or by mail at ‘The Privacy Officer’, Zurich Financial Services Australia Limited, P. O. Box 677, North Sydney NSW 2059.
1
Claimant details
Title
Surname
Given name(s)
Please state if primary or secondary cardholder
Postal address
Phone number – Private
ZU09173 - V4 03/14 - RSOS-07256-2013
Mobile
2
State
Postcode
Business
Fax
Email
Details of the credit card that was used to purchase the item being subject to this claim
Bank/Financial Institution
Name of primary cardholder
Name of secondary cardholder
Please remember to include your Credit Card Statement showing your name and details of purchase.
Zurich Australian Insurance Limited ABN 13 000 296 640, AFS Licence No. 232507. Locked Bag 2138, North Sydney NSW 2059.
For Claim Service Information please call on 132 687 (from Australia) and 0800 443 558 (from New Zealand) Fax 61 2 9995 2060.
Purchase Cover Claim Form - Page 1 of 3
3
Details of the event
Date of accident
/
/
Time of event
am
pm
Address where the event happened
Describe the event in full
Name of the person responsible for causing the loss or damage
Address of the person responsible for causing the loss or damage
Relationship to cardholder
Witness's name
Witness's address
4
Details of the lost/stolen/damaged property
The property (make and model)
Retailer and their address
Date purchased
Amount paid
(AUD $)
$
$
$
$
$
$
$
$
Amount claimed
5
$ 0
Details of police report (if property lost/stolen/wilfully damaged and incident reported to police)
Police station
Police officer's name (if known)
Report reference number
Has the above authority issued their official report?
Date
Yes
No
/
/
Time of event
am
pm
If 'Yes', please attach original report
Name of the person who made the report to the police
That person's phone number, if not claimant
Purchase Cover Claim Form - Page 2 of 3
6
Details of your other insurance
Do you have home contents or building insurance?
Name and address of insurer
Yes
State
Postcode
State
Postcode
State
Postcode
No
Policy number
Do you have jewellery or personal valuables insurance? Name and address of insurer
Yes
No
Policy number
Do you have any other insurance that could cover the subject loss? Name and address of insurer
Yes
No
Policy number
7
Have you submitted a claim for this event on one of the above policies?
Yes
No
Have you received compensation from any other party in relation to this event?
If 'Yes', please provide full details
Yes
No
Your previous claims history – please list all claims you have made in the past three years
Date
Company
Amount
Brief details of claim
$
$
$
$
$
$
8
Direct Deposit
We may elect to cash settle your claim and, should this be the case, the reimbursement amount can be deposited directly into your bank
account (no credit card accounts can be credited). Should you prefer direct deposit, please provide the following details:
Name of account
Type of account
–
BSB (Branch number)
9
Account number
Declaration
I declare that the information I have provided is accurate and correct. I have not withheld any information that would affect the result of this
claim. I understand that if the information provided is incorrect or inaccurate my claim may be refused.
SignedDate
✗ /
/
Please return this claim form to:
Zurich Australian Insurance Limited
Credit Card Claims Services
Locked Bag 2138
North Sydney NSW 2059
AUSTRALIA
Save File
Print Form
Purchase Cover Claim Form - Page 3 of 3