Make a claim on your policy.

For

At Antipodean Underwriting, we believe that Claims Service is what sets apart the best underwriters from the rest.

We take pride in offering the best claims service in the industry. Our customers are our top priority, and we go above and beyond to ensure their satisfaction. Our team of experts is always available to assist with any questions or concerns, and we work hard to make the claims process as seamless and hassle-free as possible. You can trust us to provide the exceptional service you deserve.

To make a claim on your policy, all that you need to do is fill out the online claim form below and its that simple. One of our Claims Officers will be in touch with you to help guide you through the claims process.

Claims Form

Notification of claim or circumstances out of which a claim may arise

IMPORTANT NOTICE

• Please read the Claim Form fully before answering the questions.

• The Claim Form is to be signed by the Insured or their authorised representative.

• All questions must be answered in the Claims Form. If any questions are incomplete or not answered, Antipodean Underwriting may ask for it to be re-submitted.

• Please attach copies of relevant documentation. Relevant documentation includes but is not limited to copies of your retainer, any written demands, or court documents.

• If you have any questions in relation to the completion of the Claim Form, please contact your insurance advisor or broker.

• Please do not admit any wrong doing to any third parties, make any offers of settlement without our consent, or disclose the details of your insurance policy with Antipodean Underwriting.

Section 1 Details of the Insured

Full Name of the Insured Name:

Address of the Insured:

Contact person and position:

Phone Number:

Section 2 Policy Details

Policy No.:

Policy Period:

Are there any other insurance policies that may be applicable to this notification?

Yes

If YES, please provide the following details:

Policy Holder:

Insurer:

Type of Insurance:

Period of Insurance:

Has the matter been notified to that insurer?

Yes

Section 3 Claimant details

Full name of the Claimant(s) or potential Claimant(s) (i.e. the party / parties making the claim or potential claim against you or the firm / company):

Section 4 Details of the Claim or Circumstances

What is the precise nature of the claim (i.e. the Claimant’s allegations) or the fact or circumstance that might give rise to a claim? Please elaborate on the following:

a. On what date did you first become aware of the claim or the fact or circumstances which may give rise to a claim?

b. What is the amount being claimed (if known)?

c. What are your comments in response to the claim or the fact or circumstances that may give rise to a claim?

d. In your opinion, how could this matter be best resolved?

Was the claim or the intimation of a claim made verbally:

Yes

If YES, please provide details including the date of the verbal claim or intimation:

Was the claim or the intimation of a claim made in writing?

Yes

Have you received a written demand?

Yes

If YES, please attach a copy of this together with any correspondence relating to the written demand.

If you answered YES, please confirm the date you received the written demand:

Have proceedings been issued against you?

Yes

If YES, please attach a copy of the court documents together with any correspondence relating to the proceedings.

Section 5 Details of the Insured’s Response

Are there any other parties which may have contributed to the claim or circumstance which may give rise to a claim?

Yes

If YES, please provide details:

Have you obtained legal representation to act on your behalf?

Yes

If YES, please provide details of their name, firm, address and charge out rates:

If NO, please note that you should not obtain legal representation without Antipodean Underwriting’s prior consent (please see policy terms and conditions).

Section 6 Declaration

The undersigned declares that the statement and particulars provided in connection with this claim or circumstance (whether written or oral) are true and that no material facts have been misstated or suppressed after enquiry. The undersigned agrees that should any of the information given by us change, the undersigned will give immediate notice to Antipodean Underwriting.

The undersigned agrees that Antipodean Underwriting may use and disclose our personal information in accordance with Antipodean Underwriting's Privacy Policy. The undersigned agrees that this Claim Form, together with all other information supplied to us, shall form part of the claim.

Full Name:

Position:

Your Signature:

Signature field is empty.

Date

Day

Month

Year

IT IS IMPORTANT THE UNDERSIGNED OF THE DECLARATION ABOVE IS FULLY AWARE OF THE SCOPE OF THIS CLAIM SO THAT THESE QUESTIONS CAN BE ANSWERED CORRECTLY. IF IN DOUBT, PLEASE CONTACT YOUR BROKER OR AGENT, SINCE NON-DISCLOSURE MAY AFFECT AN INSURED’S RIGHT OF RECOVERY UNDER THE POLICY.

We recommend that you keep a record of all information supplied (including copies of this Claim Form and correspondence).

Privacy Collection Statement

We are committed to protecting your privacy and complying with the Privacy Act 1988 (Cth) (‘Privacy Act’). We use your information to assess the risk of providing you with insurance, provide quotations, issue policies and assess and manage claims, on behalf of the insurers we represent. If you do not provide us with full information, we may not be able to provide insurance or assess and manage a claim. If you provide us with information about someone else, you must obtain their consent to do so. We may provide your personal information to the insurer we represent, insurance regulators and other insurance bodies as required by law.

We may also provide your information to your broker and any third party claims service providers (such as claims management companies, parties repairing or replacing the subject matter, loss adjusters and appointed law firms (and the like)). If a recipient is not regulated by laws which protect your information in a way that is similar to the Privacy Act, we will take reasonable steps to ensure that they protect your information in the same way we do or seek your consent before disclosing your information to them. We do not trade, rent or sell your information.

Our Privacy Policy contains more information about how to access and correct the information we hold about you and how to make a privacy related complaint, including how we will deal with it. By providing us with your personal information, you consent to its collection and use as outlined above and in our Privacy Policy.

APPENDIX 1

We require certain information to assess indemnity, liability and quantum in relation to the claim. Examples of the types of

information we require includes (based on the type of claim):

Crime:

• Police Reports

• Loss Assessors Reports

• Audit Reports

• Internal investigation Reports

• Statements from Witnesses

• Any Signed Confessions

• Account Statements

• Receipts and Invoices

• Cheque Requisitions and Cheques

• Money Orders and Cash Receipts

Employment Practices Breach:

• Contract of Employment

• Copy of the Claimant’s Termination Notice (if applicable)

• Fair Work Australia Application (Applicant’s Response)

• Your response to the allegations or dispute (Employers Response)

• Copies of itemised legal bills and retainer (If the Insured has obtained its own legal representation)

• Copies of any FWA judgement and Deed of Settlement

Tax Audit Costs:

• Letter from the ATO or regulatory authority notifying you of the audit

• Letter from the ATO or regulatory authority confirming the audit has been completed

• Copies of itemised invoices from the Company’s Accountant

Make a claim on your policy.

Claims Form

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