Involuntary unemployment claim form

In addition to filling out the below form, you must also provide as attachments in Section B;

A letter from your employer confirming the date your employment ceased or you were stood down, including the reason why.
Your last 4 pay slips prior to your employment ceasing or stand down.

We appreciate that everyone’s employment circumstances are unique. If you think you cannot source or provide the above, please continue to complete the below form and our claims team will discuss alternate options with you once submitted.

Section A - Your details

Required fields marked with an asterisk (*)

Policy number *First name *Surname *Date of birth *Address *State *Postcode Home telephone number

Please combine your area code and phone number. For example, 0212345678.

*Mobile phone number *Email Loan account number

Please do not put spaces between the numbers.

*Date loan contract commenced

Please do not put spaces between the numbers.

*Have you varied your loan since it first began (ie restructured, borrowed additional funds, etc)?

Yes No

If you answered 'Yes' above, please provide details

Section B - Your involuntary unemployment details

*Name of employer Address of last employer *State *Postcode Telephone *Position held *On what basis were you employed?

Permanent and 20 hours or more a week Permanent and between 10-19 hours a week Permanent and less than 10 hours a week Casual Temporary or Contract Self employed Other

If 'Other', please provide details *When did you commence the employment? *When did you cease employment or was stood down? *Reason for ceasing employment *Have you recommenced employment?

Yes No

If 'Yes', please provide date commenced *Have you registered as unemployed with Centrelink or the relevant government agency in your area?

Yes No

If 'No', why not? *Are you in receipt of unemployment benefits?

Yes No

If 'No', why not? *Are you actively seeking new employment?

Yes No

If 'Yes', what steps are you taking? *Have you ever made an insurance claim for Involuntary Unemployment before?

Yes No

If 'Yes', when? Name of insurer

Letter from employer

Please upload only PDF, JPEG, PNG or GIF files, with a maximum size of 5MB per file.

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Payslip 1

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Payslip 2

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Payslip 3

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Payslip 4

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Section C - Declaration and authorisation

I declare that:

1. the above information is true and correct and I have not withheld any relevant information. I shall also agree to supply any further information as requested by QBE.

2. I authorise Centrelink or any person or firm who has employed me to release any information sought on this claim form to QBE.

3. I acknowledge that payments are calculated to the date the unemployment certificates are stamped and signed by Centrelink.

4. I consent to QBE disclosing my personal information to and/or collecting additional information about me from investigations or legal advisors.

*Signed

Please print your full name.

*Date

This field is required.

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