Lodge a Claim - Intercept Loss Adjustors

Your Details

Full Name*

First Name Last Name

Address of Claimant*

Street Address Address Line 2 City State Postal Code Country

Move Reference No.*

Home / Work*

Mobile

Email*

Uplift Address*

Street Address Address Line 2 City State Postal Code Country

Uplift Date*

Delivery Address*

Street Address Address Line 2 City State Postal Code Country

Delivery Date*

Total value of the goods moved*

Loss details*

(and if possible, specifically how the loss occurred)

Detailed description*

(if there is insufficient space, please attach a separate schedule)

Claim Details*

Item (Brand, Make, Model, Age, etc.)	Description of Loss/Damage	Sum Insured, Declared Value or Estimated Value	Amount Claimed

Add a picture of damaged item

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, zip, Max. file size: 30 MB.

Maximum 10 files, 30MB total.

Method of Payment*

Bank Name

Account Name

BSB

Account Number

Comments

This field is for validation purposes and should be left unchanged.