Pusuant to the PRIVACY ACT 1993 the following is brought to you attention
(a) This claim form collects personal information about you
(b) The information is collectd to evaluate your claim
(c) The collection of this information is required pursuant to the terms of your insurance policy;
(d) The failure to provide this information may result in your claim being declined;
(e) You have the rights ti access to, and correction of, this information subject to the provisions of the
Privacy Act 1993
DECLARATION: Note: Failure to provide full and truthful information could result in the claim
being declined
I/We declare that the information given in this form is correct.
I/We authorise and request the Australian Police to release Spacehips Australia copies of any documents held
by the Australian Police relating to the incident giving rise to this claim. If necessary, authorityshould
be treated as a formal request pursuant to the Official Information Act, 1982.
I/We authorise the disclosure of personal information held by any other party regarding this claim.
I/We agree to Spaceships Australia releasing to other parties personal information regarding this claim.
I HAVE READ THE ABOVE & DECLARE THAT TO THE BEST OF MY KNOWLEDGE THE ANSWERS PROVIDED IN THIS FORM ARE TRUTHFUL