Claims Form

I declare that to the best of my knowledge and belief the information in this form is true and correct and I have not withheld any relevant information. I/we agree that, by submitting this form, the personal information I/we provide to CoverWise & PSC Connect Pty Ltd in this form or otherwise may be collected, held, used and disclosed in the manner set out in the Privacy policy found at www.pscconnect.com.au/privacy/, including for processing this claim.