Job Number:

Postal Address:

Contact First Name:

Contact Surname:

Contact Number:

Email:

Date of loss/ damage:

Goods moved from:

Goods moved to:

When was loss/ damage first discovered?

Please provide details of the loss/ damage incident?

Were goods professionally packed?
YesNo
Were details of loss/ damage noted at time of delivery?
YesNo
Have you notified carrier of loss/ damage?
YesNo

Description of items to be claimed	Details of loss/damage	Can the item be repaired?	Amount claimed (AUD)
		YesNo
		YesNo
		YesNo
		YesNo
		YesNo
		YesNo
Total amount claimed

Please attach before photos:

Please attach after photos:

I declare that to the best of my knowledge and belief the information in this form is true and correct and I have not withheld any relevant information. I understand that Insurers do not admit liability by the issue of this form.