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________
________
Telephone: ________
Email: ________
________
The Claims Department
________
ABN/ACN: ________
AFSL No.: ________
________
RE: INSURANCE CLAIM – Policy Number ________
Policyholder Name: ________
Claim Reference (if known): ________
Dear Sir or Madam,
I refer to the above policy of insurance issued by ________ (the Insurer) and write to lodge a formal claim under that policy in accordance with its terms and conditions, the Insurance Contracts Act 1984 (Cth) and the General Insurance Code of Practice.
1. Particulars of the Claim
Insured/Patient: ________
Provider: ________
Date services rendered/event occurred: ________
Description of the loss, event or treatment giving rise to the claim: ________
2. Supporting Documentation
In support of this claim, and consistent with my duty under sections 13 and 14 of the Insurance Contracts Act 1984 (Cth) to act towards the Insurer with the utmost good faith, I enclose the following:
(a) a completed and signed claim form;
(b) a statement from the provider;
(c) tax invoices, receipts and/or other evidence of the expenses incurred;
(d) ________
3. Amount Claimed
On the basis of the enclosed documentation, I claim reimbursement and/or indemnity in the amount of $________ (________).
4. Payment
I request that any amount payable be remitted in the following manner:
________
Account name: ________
BSB: ________ Account number: ________
5. Declaration and Authority
6. Processing and Complaints
Please find all relevant documentation enclosed with this letter. Should you require any further information or additional documentation in order to process this claim, please do not hesitate to contact me at your earliest convenience using the details provided above. Thank you for your prompt attention to this matter.
Yours faithfully,
________
Date: ________
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