Fidelity Claim Form
This Claim Form consist of:
A.NOTES
B.INSURED DETAILS
C.INCIDENT DETAILS
D.EMPLOYEE DETAILS
E.INVESTIGATIVE DETAILS
F.DECLARATION
A.Notes
1.It is most important that all questions are answered. If not applicable, write ‘N/A’.
2.The issue of this claim form is not an admission of liability by QBE.
3.If there is insufficient space or further comments on any area is considered necessary, please use additional pages.
B.Insured Details
Name of insured
Contact name
Address
State / Post Code
Mobile Telephone No. / ( ) / Business Telephone No. / ( )
E-mail / Occupation
C.Incident Details
1.Full name of suspected employee:
2.Exact title of suspected employee at time the loss was discovered:
3.Nature of employee’s duties:
4.Date at which loss was discovered: / /
5.Period when loss was incurred: / From / to /
6.By whom, and under what circumstance was the loss discovered (please give full details):
7.Is any other person implicated? / Yes No
8.If ‘Yes’, please give name and addresses of all other persons implicated: / Name(s) / Address(es)
9.Are these implicated persons your employees? / Yes No
C.Incident Details(continued)
10.Amount of cash involved / $ / Value of merchandise / $
11.Has the matter been reported to the police? / Yes No
D.Employee Details
If more than one employee, please provide a separate statement in respect of all other suspected employees.
1.Is the location of the suspected employee known? / Yes No
2.Last known address of suspected employee:
3.Previous address of suspected employee:
4.Names and addresses of employee’s nearest relatives:
5.Exact date suspected employee’s services began: / /
6.Exact date suspected employee’s services terminated: / /
7.Reason for termination of employment:
8.Has the suspected employee made oral or written confession? / Yes No
9.If no confession made, what explanation of the shortage does the suspected employee give? Please give full details:
10.Has warrant for arrest been issued? / Yes No
E.Investigative Details
1.The accounts pertaining to the loss have been audited as follows:
Date of Audit / By Whom Audits Made
/
/
/
2.To the best of our knowledge the suspected employee owns the following real and personal property:
Real property:
Personal property:
Bank accounts:
Other:
3.Has the suspected employee ever had a shortfall in cash handled? / Yes No If ‘Yes’, please give full details:
4.How is employee remunerated:
5.Amount of salary or commissions due to suspected employee at the time of discovery of loss? / $
6.Other payments due to employee? / $
Privacy
QBE includes information about how we manage your personal information in our Product Disclosure Statements and policy booklets. You can obtain a copy of the QBE Privacy Policy Statement from our website or contact in writing to,
The Compliance Manager, QBE Insurance (Australia) Limited, GPO Box 82 Sydney NSW 2001 or email:
F. Declaration
I/We declare that:
1.The information and answers given above are true, correct and complete in every detail.
2.I/We understand the claim may be refused if information is not true or is withheld.
3.I/We authorise QBE Insurance (Australia) Limited to give to and obtain from other insurers, insurance reference bureaus and credit reporting agencies any information relating to the Insured’s credit and insurance history as well as insurance claims information obtained during the course of this contract.
Signature of insured:
Title: / Date: /
QM2863-0111
QBE Insurance (Australia) Limited ABN 78 003 191 035, AFS Licence No. 239545 of 85 Harrington Street, Sydney NSW 2000
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