Fillable CUSTOMER CLAIM FORM (Australian National University)

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CUSTOMER CLAIM FORM (Australian National University)

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INSURANCE LETTER REQUEST
If this Insurance Request Form is incomplete this will delay the request being provided.
Please ensure all fields are completed before submission.
1. Customer Details
Would you like the letter: Emailed Posted
National Metering Identifier (NMI)
(This will appear on your electricity account)
2. Incident Details
Reason for req
uest
3. Declaration
I declare th
e information provided is true in every detail and that all relevant information has been provided. I
declare I am the owner or responsible for the items identified in this Insurance Request Form. I understand that
this request may be refused if information is untrue, concealed, or omitted.
Name:
Date:
Please e
mail or post your form to: claims@powercor.com.au
Locked Bag 14090 Melbourne 8001
Title
First Name
Surname
Service Address (as per Electricity Bill)
Post Code
Postal Address (if different from above)
Post Code
Telephone (H)
Email Address
Date of incident
Time of incident
Form no: 03-10-F0005 Page 1 of 1 Issue 3, 20/05/2010
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CUSTOMER CLAIM FORM (Australian National University)

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Completed 6 October 2021

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