A)Using the information below, fill in this claim form adding any details necessary. You should complete it in full ready for submission.

100 cartons of Vegemite

Each carton measures 30cm x 45cm x 30cm and weighs 10kg

4 cartons have gone missing

Own truck transportation from Sydney to Brisbane.

To access a claims form, use the following link and print your completed document:

Insured details:

• Policy number
• Claim number
• Insured name
• Postal address
• State Postcode
• Contact name
• Contact number/s Email

GST declaration

Are you registered for GST? Yes No

If 'Yes', please provide ABN number Have you claimed an input tax credit on the GST amount applicable to this policy? Yes No

If 'Yes', is the amount claimed less than 100%?

Yes No If 'Yes', please advise percentage of GST claimed is applicable to the premium %

Claim information

Date of loss/damage

Date of dispatch

Date of arrival /

Place of dispatch Place of arrival When was loss/damage first discovered?

Please provide details of the loss/damage incident Where did the loss occur?

Address where damaged goods can be inspected Consignee name and address Consignor name and address Has the event been reported to the police? Yes No

If 'Yes', please advise name and location of police station Police report number Can damaged goods be repaired? Yes No

If 'No', is there any salvage value? Yes No

If 'Yes', please advise approximate value AU$ Other insurance cover Was there any other insurance covering this event? Yes No If

'Yes, please advise insurance company name and policy number Other interested parties Please provide details including name and address of other interested parties (ie finance company, lessee)