Elkington Bishop Molineaux Insurance Brokers Pty Ltd | ABN 31 009 179 640 | AFSLN 246986 | Est 1975 Musical Instruments Claim Form | Page 1 of 2 Please complete the form and choose either EMAIL THIS FORM to email the form or PRINT THIS FORM to print then fax or post MUSICAL INSTRUMENTS CLAIM FORM Post to: Musical Instruments Division Fax: 1300 365 822 EBM PO Box 10841, Southport BC Qld 4215 IT IS A CONDITION OF YOUR POLICY THAT WRITTEN DETAILS OF THE CLAIM ARE RECEIVED BY INSURERS WITHIN 30 DAYS. PLEASE RETURN YOUR CLAIM FORM AS SOON AS POSSIBLE. 1.0 Contact Details Mobile: Fax: State: Postcode: Email: Phone: Suburb: Instructions: Privacy - We are committed to protecting your privacy. We use the information you provide to advise about and assist with your insurance. We only provide your information to insurance companies, underwriting agencies, wholesale brokers and premium funders with whom you choose to deal (and their representatives). We do not trade, rent or sell your information. If you don’t provide us with full information, we can’t properly advise you and you could breach your duty of disclosure. You can check the information we hold about you at any time. For more information about our Privacy Policy, ask us for a copy or visit our website www.ebm.com.au. By completing the form below, I certify that I am aware that any collection of personal information is used in accordance with EBM’s Privacy Policy. The issue of this Form is not an admission of liability and is issued without prejudice. BEFORE ANY QUESTIONS ARE ANSWERED, PLEASE READ CAREFULLY THE DECLARATION AT THE END OF THIS FORM WHICH YOU ARE REQUIRED TO SIGN. Name: 2.0 Claim Information Are you the Owner of the property insured? Describe how the loss/damage occured? Description of Property lost or damaged: No Yes Address: