Page 167 - claims information pack ebook_e

Example Claim Form
PART 2 Section B Claim Number (for internal use only)
Property Damage
Section B

8) Equipment used, please specify

a. Purchase price of equipment

b. Cost per day/hour (please specify) of equipment hired

c. Duration of use of equipment (days/hours – please specify)

9) Detail of other costs or expenses incurred (e.g. survey costs)

10) Residual value of equipment/goods purchased

11) Age of damaged goods replaced
22

Calculation of the total amount of the claim
You may wish to use the following table as an example of how to calculate the total amount of the claim.
Whichever method you use, you must provide an explanation of the method you have used to calculate the total
amount of the claim.
Item 7: Cost of personnel (7b +7c + 7d) +
Item 8: Cost of equipment used (Total of 8a +(8bx8c) ) +

Item 9: Other costs (e.g. survey costs) +
Item 10: Residual value of equipment purchased -
Total =

Additional Information
Are the damages referred to in this claim insured in whole or in part? Yes No

If YES, please provide full details (name of insurance company, policy type, claim submitted, amount paid,
amount insured, any exclusions, etc.)

Provide details of any other claims for compensation you have made in connection with this incident.

Provide details of any other compensation or form of income you have received (e.g. state or regional
emergency funds, charitable donations, etc.) or you will receive in connection with this incident (name
of payer, amount received, etc.). If none, state NONE.

Have you submitted additional pages/documents to this claim form? Yes No
Please specify

Please submit all supporting documents and evidence for all costs incurred as detailed above.