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Claim Form

This form must be submmited in 60 minutes

Your Details
What are you claiming for?
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 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
Customer First Name
Customer Middle Name
Customer Surname
Would you like to authorise another person to discuss your claim circumstances with us?
If Yes, we will email you an authority form for your completion and return.
Residential Address
Country
Street Number
Street Name
Suburb
Town/City
State
Postcode
Date of Birth
Preferred Contact Method
Preferred Phone Contact
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
Mailing Address
Country
Street Number
Street Name
Suburb
Town/City
State
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?
Q5. If 'other' please provide more information
Q6. When did you start working with this employer?
Q7. What was your occupation at the time of losing your job?
Q8. What was your employment status?
Q9. How many hours did you work per week?
Q10. I was employed continuously for at least 12 months prior to the date I lost my job
Q11. I was employed continuously for at least 6 months prior to the date I lost my job
Q12. How long was your break in employment, and what was the reason for it?
Q13. Have you found another job yet?
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?
Q16. If yes, are you still working for that employer?
Q17. Are you actively looking for another job?
Q18. If yes, please specify job seeking options
Q19. If 'other' please provide more information
Q20. Did the season or contract finish up earlier than expected
Q21. Has the business ceased trading permanently or commenced winding up?
Q22. Were you aware of your unemployment before taking out the policy?
Price Protection
Q1. Which of the following best describes your item?
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?
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?
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?
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?
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?
Q20. Was the retailers price reduction due to one of the following?
Q21. Have you already made a claim for an earlier price reduction on this item?
Q22. Have you also made a claim for Merchandise Protection for this same item?
Disability Information
Q1. What is the main medical condition that has stopped you from working?
Q2. Have you consulted a doctor regarding this condition?
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?
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?
Q6. What was the first date you were certified as unfit for work for this illness/injury?
This is the 'from' date on your medical certificate.
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?
Q9. Was the illness/injury due to any of the following?
Q10. Has your doctor certified you entirely fit to return to your usual duties at work?
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?
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?
Q14a. How long were you working continuously, prior to the date of the illness/injury certification?
Q14b. What was your employment status?
Q14c. Average hours worked per week?
Q15. Have you returned to work?
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?
Q19. Additional Information (if required).
Disclosure Acknowledgement
I acknowledge the above disclosure
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