Section One - Claim Details
Please fill out the following details:
Claim Notification Date:
25/01/2021
Title*:
-- select --
Mr
Mrs
Ms
Miss
Dr
First Name*:
Surname*:
Date of birth (DD/MM/YYYY)*:
Are you the insurance account holder?*:
-- select --
Yes
No
Driver’s License/Passport Identification Number*:
Daytime contact no*:
Mon-Fri 9am-6pm AEST
After hours contact no:
Email*:
Confirm Email Address*:
Would you like to authorise another person(s) on your insurance claim?*:
Yes
No
Authorised Person 1 Title:
-- select --
Mr
Mrs
Ms
Miss
Dr
Authorised Person 1 First Name:
Authorised Person 1 Surname:
Relationship to Authorised Person 1:
Authorised Person 2 Title:
-- select --
Mr
Mrs
Ms
Miss
Dr
Authorised Person 2 First Name:
Authorised Person 2 Surname:
Relationship to Authorised Person 2:
Customer Address Line 1*:
Customer Address Line 2:
Customer Address Line 3:
Suburb*:
Postcode*:
State*:
Please select...
NSW
VIC
QLD
NT
ACT
SA
WA
TAS
Insured Mobile Number*:
Insured IMEI Number / Serial Number*:
You can locate your 15 digit IMEI number via your contract, purchase receipt, original packaging/box, dialing "*#06#", on your SIM tray or under your battery at the back of your handset.
Has your device been exchanged under warranty or repair?*:
-- select --
Yes
No
If yes, please attach change of IMEI paperwork:
Make/Model of Device*:
Colour of Device*:
Date and Time of Incident (DD/MM/YYYY)*:
-- select --
12:00am
12:30am
01:00am
01:30am
02:00am
02:30am
03:00am
03:30am
04:00am
04:30am
05:00am
05:30am
06:00am
06:30am
07:00am
07:30am
08:00am
08:30am
09:00am
09:30am
10:00am
10:30am
11:00am
11:30am
12:00pm
12:30pm
01:00pm
01:30pm
02:00pm
02:30pm
03:00pm
03:30pm
04:00pm
04:30pm
05:00pm
05:30pm
06:00pm
06:30pm
07:00pm
07:30pm
08:00pm
08:30pm
09:00pm
09:30pm
10:00pm
10:30pm
11:00pm
11:30pm
Incident Location*:
Was your device in your possession?*:
-- select --
Yes
No
User Details
User Title:
-- select --
Mr
Mrs
Ms
Miss
Dr
User Full Name:
Relationship:
Have you been directed to Risk Insure via a Vodafone store?
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Yes
No
Store Suburb*:
Is your Vodafone account fully paid up to date with no outstanding amounts?*
-- select --
Yes
No
Please note if your account has any amounts outstanding, processing of your claim may be delayed
What type of claim do you wish to make?*:
-- select --
Damage
Loss/Theft
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