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Your Details

What are you claiming for?

Select Price Protection Involuntary Unemployment Disability

For more information, read 'What type of claim do I need to make?' above.

Is your insurance on a personal loan or credit card?

Personal Loan

Credit Card

Personal Loan Number

If you have more than one account with valid insurance, we will assess your claim against each of them and let you know the outcome.

Credit Card Account/Card Number

A valid Latitude account or credit card number.

Customer Title

Select Mr Mrs Miss Ms Dr

Customer First Name

Customer Middle Name

Customer Surname

Would you like to authorise another person to discuss your claim circumstances with us?

Yes

No

If Yes, we will email you an authority form for your completion and return.

Residential Address

Country

Select Australia New Zealand

Street Number

Street Name

Suburb

Town/City

State

Select NSW ACT QLD WA VIC SA TAS NT

Postcode

Date of Birth

Preferred Contact Method

Email

Phone

Letter

Preferred Phone Contact

Mobile

Home

Work

Preferred Phone Number

Other Phone Number

Email Address

Confirm Email Address

Please re-type your email address to confirm.

Is mailing address the same as residential address

Yes

No

Mailing Address

Country

Select Australia New Zealand

Street Number

Street Name

Suburb

Town/City

State

Select NSW ACT QLD WA VIC SA TAS NT

Postcode

Involuntary Unemployment

Q1. What was your last day worked?

Q1a. What date were you notified of your impending unemployment?

Q2. Company Name

Q3. Employer Contact Number

Q4. What was the reason for stopping work?

Select Shortage of Work Redundancy Unsuitable for Job End of Contract or Season Misconduct with No Criminal Activity Voluntary Resignation Abandonment Normal Pregnancy Sickness/Injury Reduced Hours with Current Employer Criminal Activity The Business has Temporarily Ceased Trading Strike or Lockout Partnership Discontinued War or Warlike activities Other

Q5. If 'other' please provide more information

Q6. When did you start working with this employer?

-- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

-- January February March April May June July August September October November December

Q7. What was your occupation at the time of losing your job?

Q8. What was your employment status?

Select Temporary Casual Self Employed Seasonal Fixed Term Contract Part-Time Full-Time

Q9. How many hours did you work per week?

Select 1-15 16-19 20-29 30+

Q10. I was employed continuously for at least 12 months prior to the date I lost my job

Yes

No

Q11. I was employed continuously for at least 6 months prior to the date I lost my job

Yes

No

Q12. How long was your break in employment, and what was the reason for it?

Q13. Have you found another job yet?

Yes

No

Q14. When did you start working with your new employer?

Q15. Did you have more than 1 job at the time you lost the job you are claiming for?

Yes

No

Q16. If yes, are you still working for that employer?

Yes

No

Q17. Are you actively looking for another job?

Yes

No

Q18. If yes, please specify job seeking options

Select Registered With Employment Agency Employment Website Government Job Agency Independent Job Seeking I Am Using Multiple Methods Other

Q19. If 'other' please provide more information

Q20. Did the season or contract finish up earlier than expected

Yes

No

Q21. Has the business ceased trading permanently or commenced winding up?

Yes

No

Q22. Were you aware of your unemployment before taking out the policy?

Yes

No

Price Protection

Q1. Which of the following best describes your item?

Select Whitegoods Electronics Appliances Furnishings Health, Fitness & Sport Footwear Clothing Jewellery etc Cash or Equivalent Perishable Items Animals, Plants Other

Q2. What item are you claiming for? Include a description (including type of goods, brand, etc)

Please enter what the item is. For clothes include the type and brand.

Q3. Gender of the clothing?

Female

Male

Unisex

Q4. What size is the item?

Q5. What colour is the item?

Q6. What Brand is the item?

Q7. What Model/Style is the item?

Q8. Date of Purchase

Q9. What date did you notice the price reduction

Q10. Is the sale item the same as the item purchased?

Yes

No

Q11. How much did you pay for the item when you bought it?

Q12. What is the reduced price of the item?

Q13. Did you make the entire payment on this card?

Yes

No

Q14. How much was paid on this card?

Q15. Where was the item purchased? (Retailer)

Q16. Where did you see the item reduced in price? (Retailer)

Q17. When you bought the item, did you pay extra for an extended warranty?

Yes

No

Extended warranty payments are not covered.

Q18. What was the amount you paid excluding the extended warranty

Q19. Was the item purchased in one of the following ways?

Select Used/Second Hand Special Order, Tailor Made Or One Of A Kind Closing Down Sale Etc Floor Display, Seconds, Damaged, Imperfect None of the above

Q20. Was the retailers price reduction due to one of the following?

Price Matching by the Retailer

Conditional On You Making A Cash Payment

A Special Deal Involving Other Items or Benefits

Reduced as Normal Sale

Q21. Have you already made a claim for an earlier price reduction on this item?

Yes

No

Q22. Have you also made a claim for Merchandise Protection for this same item?

Yes

No

Disability Information

Q1. What is the main medical condition that has stopped you from working?

Q2. Have you consulted a doctor regarding this condition?

Yes

No

Q2a. What was the date that you first suffered the illness or injury that you are claiming for?

Q3. Is the condition you are claiming for caused as a direct result of an accident?

Yes

No

Q4. What was the date of the diagnosis of your illness/injury that has stopped you from working?

Q5. Has the doctor certified you as being unfit for your normal work duties?

Yes

No

Q6. What was the last day you worked prior to being certified unfit with this illness/injury?

Q7. What was the last date you have been certified as unfit for work for this illness/injury?

This is the 'to' date on your most recent medical certificate.

Q8. Has the condition you are claiming for been diagnosed as one of the following?

Select Heart Attack Cancer Stroke Major Organ Transplant Coronary Artery Disease Requiring Surgery Kidney Failure Other

Q9. Was the illness/injury due to any of the following?

Select Normal Pregnancy Warlike Activity Criminal Activity None of the Above

Q10. Has your doctor certified you entirely fit to return to your usual duties at work?

Yes

No

Q11. What date does your doctor anticipate you will return to work?

Q12. Have you previously had symptoms, advice, or treatments from a medical practitioner for the same condition prior to your certification?

Yes

No

Q13. What was the initial date you had symptoms, advice, or treatments for the same condition?

Employment Details

Q14. Were you employed at the time you suffered the illness or injury that you are claiming for?

Yes

No

Q14a. How long were you working continuously, prior to the date of the illness/injury certification?

Select less than 1 month 1 - 5 months 6 months +

Q14b. What was your employment status?

Select Full-Time Part-Time Fixed Term Contract Seasonal Self Employed Casual Temporary

Q14c. Average hours worked per week?

Select 1-15 16-19 20-29 30+

Q15. Have you returned to work?

Yes

No

Q16. What date did you return to work?

Q17. Please describe the circumstances of your return to work.

e.g. have you returned full time, part time, on light duties, or as part of a rehab program and what hours are you now working.

Q18. Average hours worked per week in your job up to today's date?

Select 1-15 16-19 20-29 30+

Q19. Additional Information (if required).

Disclosure Acknowledgement

I acknowledge the above disclosure

I acknowledge the above disclosure

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