NT Police, Fire and Emergency Services
Contact Us
Information Access Team
PO Box 39764
General Property Report
WINNELLIE NT 0821
for Insurance Companies/Loss Assessors
Telephone: (08) 8985 8930
Application Form
xxxxxx.xxxxxxxxxxx@xx.xxx.xx
Use this form if you are an insurance company or loss assessor acting on behalf of a client and are requesting
a Police Report for information about property that has been lost, stolen or damaged.
This application form is
NOT to be used when requesting Motor Vehicle Crash Reports. For further information
in relation to your request, please do not hesitate to contact us.
General Property Insurance Reports attract a fee pursuant to the
Police Administration (Fees) Regulations of
50 Revenue Units per report. Revenue Units are governed by the Northern Territory
Revenue Units Act 2009
and are subject to change 1 July each year.
The Northern Territory Department of Treasury and Finance determine the value of a Revenue Unit for all
Northern Territory Government Departments.
Please refer to the current Fee Advice located at the below link if you are unsure of the fee associated with this
request:
http://www.pfes.nt.gov.au/Access-to-information.aspx
Unfortunately, these fees can
NOT be waived under any circumstances.
Please send your completed application form and proof of payment to the Information Access Team by email,
fax or mail. If you submit your form at an NT Police Station, the receiving officer will forward your application to
the Information Access Team for you.
Contact Details
Insurance Company/Authorised Loss Assessor:__________________________________________________
Name of Representative:____________________________________________________________________
Phone: (B/H)_____________(A/H)_______________ Postal Address:
Email:______________________________________ ___________________________________________
Fax:_______________________________________
___________________________________________
___________________________________________
Insurance Details
Property Details
Claim Number: ______________________________ Owner: ___________________________________
Address:____________________________________
___________________________________________
Offence Details (enter as many fields as you are able)
PROMIS or ICAD Number: __________________________________________________________________
Date of Offence: __________________________________________________________________________
Place of Offence: _________________________________________________________________________
Name of Person who Reported Offence: _______________________________________________________
Date / Time of Report: _____________________________________________________________________
Description of Property (or attach list): _________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Sign Here ___________________________________
Date _____________________________________
Privacy
Northern Territory Police, Fire and Emergency Services (NTPFES) is col ecting this information to ensure that
the correct person is entitled to receive the information requested. This collection is authorised or required by
the
Information Act (NT) and/or the Northern Territory
Police Administration Act. The information provided on
this form is only used to identify the applicant for the purpose of providing the information requested. You have
the right to request access to any of your personal information held by NTPFES. For more information, please
contact NTPFES by telephone on (08) 8985 8926.
This must be completed by the Receiving Officer before forwarding to the Information Access Team
Date application received:___________________________________________________________________
Satisfied as to Identity of Applicant: Yes
Basis of Satisfaction of Identity:_______________________________________________________________
Receipt Number:_________________________________ Payment Amount:__________________________
Receiving Officer’s Name & Position (please print):_______________________________________________
Signature of Receiving Officer:_______________________________________________________________
Updated: 21 January 2019
NT Police, Fire and Emergency Services
Contact Us
Information Access Team
PO Box 39764
General Property Report for Insurance
WINNELLIE NT 0821
Companies/Loss Assessors
Telephone: (08) 8985 8930
Payment Options
xxxxxx.xxxxxxxxxxx@xx.xxx.xx
Bank Transfer via Internet or Telephone Banking – only within Australia
Our bank details are:
National Australia Bank (NAB)
Account Name: Receiver of Territory Monies (RTM)
BSB: 085-461
Account Number: 161610000
Description: Applicant’s/Your Name – 131141
You must also attach a copy of the transfer confirmation to this application form and send it to the Information
Access Team at NT Police, Fire and Emergency Services.
Credit Card – this is the only method of payment for overseas customers
Credit card payments can be made to the Receiver of Territory Monies (RTM) over the telephone or by email.
You must advise the RTM that you are paying for a General Property Report for Insurance, with the general
ledger code
16JBDA02 - 131141 and tax code
N00. You must also attach a copy of the RTM receipt to this
application form and send it to the Information Access Team at NT Police, Fire and Emergency Services.
The RTM can be contacted during office hours on
(08) 8999 1606 or by email xxxxxxxxx@xx.xxx.xx
Cheque / Money Order
Cheques and money orders should be made payable to the Receiver of Territory Monies (RTM) and sent with
the completed application form to the Information Access Section of NT Police, Fire and Emergency Services.
Updated: 21 January 2019
