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  Please complete the form below to have us appoint a service provider for you.


Claim No.  
Your Name:  
Insurer*:  
Phone Number*:  
Email*:  
Fax No:  
   
JOB DETAILS*
DAMAGE
INDUSTRIAL
COMMERCIAL
DOMESTIC
MINOR
MEDIUM
MAJOR
LEGEND:
MINOR = Damage less than $12k in value
MEDIUM = Damage between $12k - $50k in value
MAJOR = Damage greater than $50k in value
   
Postcode*:  
   
Comments:  
 
 
 
 
 
 *Required Information