Initial Contact Information Step 1 of 5 20% Initial Contact InformationRM Reference #:*Date and Time of Initial Contact*Tick this box to confirm* Please confirm Name & Address of Insured matches entries in Encircle & RM. "Am I speaking with the homeowner?"*Please enter put in the name of the person you are speaking with now. This enables us to confirm if they are the owner/s of the property or a tenant or if they are representing the homeowner/tenant. Can I confirm the date of the loss please?* Event Type - "May I just confirm the event type?"* Contents Fire Water Storm Sewerage Mould Meth Hail Damage Other Is this claim in relation to a large weather event/fire? (e.g. cyclone, major storm)If answer is Yes, Select "Other" and provide details No OtherOtherHave any emergency services attended site?If answer is Yes, Select "Other" and provide details No What emergency works have been carried out? Electrical Roof Tarping Windows Boarded Other/Details of aboveHas your roofing been impacted by the event?* Yes No What type of Roofing?Has the access to your property been impacted by the event? Water over roads Powerlines down Trees down Driveway not accessible Localized Flooded Roads Other/More detailsAre there any broken windows / glass within the house?*If answer is Yes, Select "Other" and provide details No Are there any residents that have a deficient immune system?* No If answer is Yes, Select "Other" and provide detailsIs there anything else you wish to let us know in response to our services and / or about your health?:*If answer is Yes, Select "Other" and provide details No Source of LossWhat was the source of loss?*eg where did the water come from (Escape of Liquid - Burst flexi-hose, Filter pipe on fridge, washing machine, overflow bathtub)If Water Related - "Has the leak been fixed or source of water been repaired?"*If answer is Yes, select "Others" and provide who has done repairs No Have you or the insurance company appointed a plumber?If answer is Yes, Select "Other"' and provide details No Does a plumber or other key trade personnel need to be arranged?If answer is Yes, Select "Other"' and provide details No If Water Related " Is there any water still on the floor/s?If Yes, Select "Other" and provide details on what areas? (Note this is classed as '"standing water" in RM) No Affected AreasIs the site, Single Storey or Double Storey* Single Storey Double Storey AreasC-CarpetV-VinylT-TilesH-HardwoodO-OtherMaster BedroomWalk in RobeEnsuiteBedroom #2Bedroom #3Bedroom #4Bedroom #5Study/OfficeBathroomLaundryKitchenPantryDiningFamilyLiving /LoungeRumpusHallway #1Hallway #2EntranceToiletLinen CupboardAreas1. Master Bedroom C-Carpet V-Vinyl T-Tiles H-Hardwood O-Other 2. Walk in Robe C-Carpet V-Vinyl T-Tiles H-Hardwood O-Other 3. Ensuite C-Carpet V-Vinyl T-Tiles H-Hardwood O-Other 4. Bedroom #2 C-Carpet V-Vinyl T-Tiles H-Hardwood O-Other 5. Bedroom #3 C-Carpet V-Vinyl T-Tiles H-Hardwood O-Other 6. Bedroom #4 C-Carpet V-Vinyl T-Tiles H-Hardwood O-Other 7. Bedroom #5 C-Carpet V-Vinyl T-Tiles H-Hardwood O-Other 8. Study/Office C-Carpet V-Vinyl T-Tiles H-Hardwood O-Other 9. Bathroom C-Carpet V-Vinyl T-Tiles H-Hardwood O-Other 10. Laundry C-Carpet V-Vinyl T-Tiles H-Hardwood O-Other 11. Kitchen C-Carpet V-Vinyl T-Tiles H-Hardwood O-Other 12. Pantry C-Carpet V-Vinyl T-Tiles H-Hardwood O-Other 13. Dining C-Carpet V-Vinyl T-Tiles H-Hardwood O-Other 14. Family C-Carpet V-Vinyl T-Tiles H-Hardwood O-Other 15. Living/Lounge C-Carpet V-Vinyl T-Tiles H-Hardwood O-Other 16. Rumpus C-Carpet V-Vinyl T-Tiles H-Hardwood O-Other 17. Hallway # 1 C-Carpet V-Vinyl T-Tiles H-Hardwood O-Other 18. Hallway # 2 C-Carpet V-Vinyl T-Tiles H-Hardwood O-Other 19. Entrance C-Carpet V-Vinyl T-Tiles H-Hardwood O-Other 20. Toilet C-Carpet V-Vinyl T-Tiles H-Hardwood O-Other 21. Linen/Cupboard C-Carpet V-Vinyl T-Tiles H-Hardwood O-Other If other area/s affected list here and note flooring type. GeneralAre there any electrical fittings (e.g lights/fans/power-points) that have been affected by water? *eg. if kitchen burst pipe, check under cupboards for dishwasher power-point which is where the burst pipe has been If answer is Yes, Select "Other"' and provide details No Have you or the insurance company appointed an electrician?*If answer is Yes, Select "Other"' and provide details No N/A Are there any unsafe conditions that you know of?*If answer is Yes, Select "Other"' and provide details No Are there any sagging ceilings due to water?*eg 2 storey/units home with burst pipe upstairs leaking through ceiling If answer is Yes, Select "Other"' and provide details No N/A Is there power available to the site?*Power needed for extraction and equipment set up Yes No Is there any large or heavy furniture in the affected area/s*If answer is Yes, Select "Other"' and provide details No Does anyone in the household have any specific health issues that we need to be aware of and factor in asthma/oxygen*The reason we ask this is that due to the nature of the work that we carry out may require leaving noisy machines on site for 24 hrs a day for several days. If answer is Yes, Select "Other"' and provide details No Have you or anyone based at the property been diagnosed or developed symptoms or been advised to self-isolate by a health professional?" in regards to the current Coronavirus?If answer is Yes, Select "Other"' and provide details No Do you consent for our staff to enter your property to perform works as part of the insurance claim? Yes No Has anyone else inspected the property?*If answer is Yes, Select "Other" and provide details. Eg. Assessor, Insurance Company Builder No Is there anything else you would like us to know? OFFICE USE ONLYName of RM Team Member completing this form* Angela Kingman Ashleigh Normington Skye-Lee Coveley Brent Hemsworth Time and Date of Initial Appointment*From your conversation with the client, have you identified that this customer maybe experiencing any form of vulnerability? Please refer to your training notes if necessary.*If answer is Yes, Select "Other" and provide your reasons for identification. Yes No Age Disability Mental Health Condition Family Violence Language and literacy barriers Cultural Backgrounds Financial or social distress Other/Reason for identification
