By submitting this form, you acknowledge that:

• The information you have provided is true and accurate.
• Your request may be refused if information is deemed untrue or incorrect.
• Delays may occur in processing your request if insufficient information has been submitted.
• Personal information collected on this form will be used to process and process your request.
• Completion of this form is not a guarantee that your request will successful.
• If we are unable to locate a supply event relating to your request we will be unable to complete your request.
• We will notify you in writing if your request has been unsuccessful.

Privacy Declaration
Personal details provided are collected and used for the purposes of managing customer claims on the AusNet Services electricity and gas distributions networks. The information provided will be treated as confidential and only disclosed to our employees and agents to allow processing of your claim. If you wish to gain access to the information you have provided, please contact us on our claim enquiry numbers listed below.