Page 1 of 6
Mobile Plant & Equipment Insurance
Claim Form
A. Your Information
Relationship to Chubb: Company:
Name:
Address:
City/Suburb: State: Postcode: Country:
Phone No: Mobile No: Email:
B. Policy Holder/Insured/Beneciary Information
Policy No: Policy Type:
Name:
Address:
City/Suburb: State: Postcode: Country:
Phone No: Mobile No: Email:
C. Type of Claims - please mark each relevant section of the policy
Section 1 – Damage to Machines
Section 2 – Increased Costs of Working
Section 3 – Loss of Income
Section 4 – Registered Machine Liability
Section 5 – General Liability
D. Description of the Loss
Insured machine/vehicle
Make & model: Year:
Registration number: Engine number:
Serial number: Gross vehicle mass:
Registered owner of machine/vehicle?
What is the extent of damage to your machine/vehicle?
Where can it be inspected?
Was your machine/vehicle towed?
Yes
No
If Yes, by whom:
Can the machine/vehicle be driven safely?
Yes
No
Page 2 of 6
Insured machine/vehicle cont’d
Was the machine/vehicle hired at the time?
Yes
No
If Yes, wet or dry hire (wet with your operator, dry without your own operator)
Wet
Dry
Who hired the machine/vehicle?
Their address:
City/Suburb: State: Postcode:
Were conditions of hire agreed upon prior to the job? (please attach a copy of the conditions of hire to this claim form)
Yes
No
Is the damaged machine/vehicle under any nance?
Yes
No
If Yes, please provide the following details of the nancier:
Financier name: Contact number:
Postal address:
Describe the task being performed by the machine/vehicle at the time of the incident:
Have you obtained any repair quotations? (If Yes, please attach to this claim form)
Yes
No
Details of driver/operator
Name of driver/operator:
Their address:
City/Suburb: State: Postcode:
Phone number: Date of birth:
Licence number: Expiry date: Years licenced: years
Operators ticket details: Expiry date: Years licenced: years
Operators experience with this type of machine:
Was the operator an employee of the insured?
Yes
No
If No, please state relationship:
Has the operator been reported for or convicted of any offence in connection with the use, operation or control of any mobile
machinery or motor vehicles during the previous 5 years?
Yes
No
If Yes, please provide details:
Page 3 of 6
Details of driver/operator cont’d
Did the operator consume any intoxicating liquor or take any drugs during the twelve (12) hours prior to the incident?
Yes
No
If Yes, please provide details:
Did the operator undergo a test (blood, breath etc.) for alcohol and/or drugs?
Yes
No
If Yes, please provide the results:
Incident/claim details
Date of incident: Time of incident (am/pm):
Location of incident:
City/Suburb: State: Postcode:
How did the incident occur? (Please provide a precise description)
What was the condition of the road/site at the time of incident?
Wet
Dry
Loose
What speed was the machine/vehicle doing at the time of the incident?
Estimated speed of the other party at the time of the incident (if applicable)
Who do you consider at fault?
Yourself
Other party
If Other party, please state why
Were there any witnesses?
Yes
No
If Yes, please provide details:
Was the incident reported to Police and/or Workcover?
Yes
No
Name of oficer:
Police station or authority: Date reported:
Name of the person who reported the matter to the authorities:
Did the Police state who was responsible?
Yes
No
If Yes, please provide details:
Page 4 of 6
Other parties, if applicable
Name of driver: Age: years
Their address:
City/Suburb: State: Postcode:
Licence number: Registration number: Type of vehicle:
Name of owner:
Owners address:
City/Suburb: State: Postcode:
Phone number:
Their Insurance company: Policy number:
Did this machine/vehicle have to be towed from the incident scene?
Yes
No
Was there more than one (1) other party involved?
Yes
No
If Yes, please provide details:
Legend
Please draw a sketch of the incident/site location. Indicate centre of roadway, direction and locations of vehicles and location of trafic.
INDEX: Indicate Insured’s vehicle (A), Other party’s Vehicle (B), (C), (D) etc.
(Please name Third Party)
Page 5 of 6
Chubb Insurance Australia Limited, Claim Privacy Consent and Declaration
Claim Privacy Consent
Chubb Insurance Australia Limited (Chubb) ollects, uses and retains your personal information in accordance with the
requirement of the Privacy Act 1988 (Cth) and the Australian Privacy Principles (APPs), as amended or replaced from time-to-
time. You can access a copy of our Privacy Policy on our website at https://www.chubb.com/au-en/footer/privacy.html or by
contacting our customer relations team.
Your personal information will be used by Chubb, or third parties engaged by Chubb, for the purpose of assessing your claim or
your entitlement to benets and, if the claim is accepted, for administration of the claim and for planning, product development
and research purposes including customer surveys.
In so far as it is relevant to the claim, your personal information may include:
a) information that is health information or sensitive information, including, without limitation, your medical history, any
treatment received by you and any medication taken or prescribed for you (at any time) or your health insurance claims
history, including Medicare;
b) information relating to other insurance policies, including terms and conditions and claims history;
c) details of your employment including position, period of employment, remuneration, hours worked and duties performed
(at any time);
d) information relating to your income, assets, liabilities and solvency;
e) information from third persons who may have information relevant to your eligibility to receive a benet, or your entitlement
to receive an ongoing benet;
f ) payment or billing information, such as bank account details, direct debit and credit card details or premium funding and
insurance payment arrangements; and
g) any other personal information that you may provide to Chubb or its third party contractors.
Collection from and Disclosure to Third Parties
To assess and process your claim Chubb may need to collect your personal information from third parties such as, but not limited
to, your insurance broker, claims reference services, government organisations (for example, social security agencies or taxation
ofices), your doctor or other health service provider, any forensic accountant or investigator retained by Chubb, your employers
(past and present), your accountant and any businesses which provide information about the commercial activities of persons or, if
you are, or have been, bankrupt the trustee of your estate.
Chubb may disclose your personal information, including health and sensitive information, to other entities within the Chubb
Group, other insurers, our reinsurers or third parties, including contractors and contracted service providers (such as assessors or
investigators) who we, or those other Chubb Group entities, have engaged to provide a specic service related to the administration
of your claim and the policy. Those entities may be located overseas, for example the regional head ofices of Chubb in Singapore,
UK or USA or third parties with whom we or those other Chubb Group entities have subcontracted to provide a specic service for
us, which may be located outside of Australia (such as in the Philippines or USA). These entities and their locations may change from
time to time. Please contact us, if you would like a full list of the countries in which these third parties are located.
Chubb may also disclose your personal information to witnesses in respect to your claim and to government agencies including the
police (where we are compelled to by law).
If you’d like a copy of your personal information or wish to correct or update it, want to withdraw your consent to receiving offers
of products of services from us or persons we have an association with, please complete Our Personal Information Request Form
online or download it from https://www.chubb.com/au-en/footer/privacy.html and return to CustomerService.AUNZ@chubb.com
or contact our customer relations team on 1800 815 675.
If You would like more information about how Chubb manages your personal information, please review Our Privacy Policy for
more details, or contact: contact the Privacy Ocer, Chubb Insurance Australia Limited, GPO Box 4907, Sydney NSW 2001,
Tel: +61 2 9335 3200 or email Privacy.AU@chubb.com.
If You are not satised with our organisation, services, Our response to Your enquiry, or You have any concerns about Our treatment
of Your Personal Information or You believe there has been a breach of Our Privacy Policy, or You are not satised with any aspect
of your relationship with Chubb and wish to make a complaint, please contact our Complaints and Customer Resolution Service
(CCR Service), Chubb Insurance Australia Limited, GPO Box 4065. Sydney NSW 2001, P +61 2 9335 3200, F +61 2 9335 3411,
E complaints.AU@chubb.com.
For more information, please read Our Complaints and Customer Resolution policy on our website at
https://www.chubb.com/au-en/customer-service/complaints-customer-resolution.html.
Please note if you do not consent to the terms of this Privacy Consent or revoke your consent, Chubb may not be able to process or
assess your claim.
Page 6 of 6
About Chubb in Australia
Chubb is the world’s largest publicly traded property and casualty insurer. With operations in 54 countries and territories, Chubb
provides commercial and personal property and casualty insurance, personal accident and supplemental health insurance,
reinsurance and life insurance to a diverse group of clients. As an underwriting company, we assess, assume and manage risk with
insight and discipline. We service and pay our claims fairly and promptly. The company is also dened by its extensive product
and service oerings, broad distribution capabilities, exceptional nancial strength and local operations globally. Parent company
Chubb Limited is listed on the New York Stock Exchange (NYSE: CB) and is a component of the S&P 500 index. Chubb maintains
executive oces in Zurich, New York, London, Paris and other locations, and employs approximately 34,000 people worldwide.
Chubb, via acquisitions by its predecessor companies, has been present in Australia for 100 years. Its operation in Australia (Chubb
Insurance Australia Limited) provides specialised and customised coverages, including Business Package, Marine, Property,
Liability, Enery, Professional Indemnity, Directors & Ocers, Financial Lines, Utilities, as well as Accident & Health insurance, to
a broad client base, including many of the country’s largest companies. Chubb also serves successful individuals with substantial
assets to insure and consumers purchasing travel insurance. With ve branches and more than 800 sta in Australia, it has a wealth
of local expertise backed by its global reach and breadth of resources.
More information can be found at www.chubb.com/au.
Contact Us
Chubb Insurance Australia Limited
ABN: 23 001 642 020 AFSL: 239687
Grosvenor Place
Level 38, 225 George Street
Sydney NSW 2000
O +61 2 9335 3200
www.chubb.com/au
Chubb Mobile Plant & Equipment Insurance Claim Form, Australia. Published 02/2022.
©2022 Chubb Insurance Australia Limited. Chubb®, its logos, and Chubb.Insured.
SM
are protected trademarks of Chubb. Chubb05370222
Privacy Consent, Declaration and Authority
I:
• consent to the collection, use and disclosure of my personal information in accordance with Chubb’s Privacy Policy and this
document for the assessment of my claim. This consent remains valid unless I alter or revoke it by giving written notice to Chubb
as outlined above;
• understand that by investigating my claim or by accepting proof of my claim, Chubb has made no acceptance of liability, nor
waived any of its rights in defense of any claim arising under the insurance policy;
• agree to use my best endeavors and render all reasonable assistance and co-operation to Chubb in the assessment of my claim;
• conrm that any information that I supply will be true and correct and that I will not withhold any information likely to affect the
acceptance or handling of my claim;
• understand that my claim may be denied if the information supplied is untrue, or I have not revealed all relevant facts;
• authorise any person or entity, including but not limited to the third parties referred to above, to provide to Chubb such
personal information as Chubb considers relevant for its assessment of my claim;
• authorise Chubb to disclose my personal information (including sensitive/health information) to other third parties referred to
above (who may be located overseas) where relevant to the assessment of my claim;
• appoint Chubb to do everything necessary including to execute on my behalf any documents or do such acts as required to give
effect to this Privacy Consent, Declaration and Authority.
Signature of Claimant
Name of Claimant Date
Please attach any
supporting documentation and email along with this completed Claim Form to [email protected]
Submitting Claim Form
