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HOP Air Conditioner Insurance Claim Form

Personal Details

Full Name:*

HOP Address:

Phone:

Payroll ID:

Please provide us with a brief description of the problem, based on the qualified repairers report:

You must attach an itemised invoice and written explanation of what caused the problem from the qualified repairer. If this is not supplied your claim will not be able to be processed. Approved amount will be included in your next pay.

History

Is this the first air-conditioner claim you have made?

Yes

If no, please provide details of last claim - year and brief description of problem:

Declaration

I declare the information provided above is true and accurate. I understand that the money paid to me is for me to pay the contractor directly, along with any other monies due but not insured by Pilbara Iron.

Employee Code of Applicant:

Date:

* Required Field