Claim Submission Form

Please fill in this form to the best of your ability and make sure to complete all relevant fields. If you are unsure or don’t have enough information, please skip or type in N/A.

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A) Details of Membership

B) Details of Event

C) Claims for loss by BURGLARY, THEFT or MALICIOUS DAMAGE

D) Cost of Damages

Please complete for all items being claimed for, attaching additional sheets as necessary

Loss of Property

Description of property for which loss is claimed Serial No's of items Current Replacement Cost Value of Salvage (if any) Date of purchase or acquisition Amount of Loss or damage claimed

Damage of Property

Description of Property and scope of damage Name of repairer (invoice / quotation to be attached) Name of repairer (Invoice) Cost of repairs

Please Note:

(1) Tax Invoices for repairs or replacement must be submitted.

(2) Where an item of equipment must be replaced, and you propose to replace that item with:

  • :- The same brand of equipment, but a different model; or
  • :- The same brand of equipment, but a different model; or

You must indicate whether the replacement equipment is the equivalent of, or better or more extensive than, the equipment it is replacing.

E) Declaration

Being a Member / on behalf of the Member confirm that the information I have given in this form is true and I understand that The Retail Mutual may exercise its discretion to provide cover

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