Claim Notification Date: 21/09/2017

Title*: -- select -- Mr Mrs Ms Miss Dr

First Name*:

Surname*:

Date of birth (DD/MM/YYYY)*:

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 the IMEI 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? -- select -- 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