Marcus Clarke General Assurance Company Group
“We’ll look after you for the term of your natural life!”
Insured Statement Section Policy Number: 18671922
Third Party Fire and Snake
Injured Person to Complete This Part
Insured Member’s Full Name: The Drover’s Wife
Date of Birth: 01/07/1866
Address: ‘Dundrovin’, Nineteen Miles from Main Rd, Woop Woop, NSW 2422
Date of Accident: 01/07/1896
Date first treated by Doctor: N/A
Where did the accident occur?: The kitchen
Describe injury: Burns to arms
Describe fully how accident occurred: Earlier in the day, a black snake had gone under the house. When it came out, I beat it to death with a stick, and threw it on the fire. Unfortunately, this resulted in extensive second degree burns to my hands.
List any previous claims during the life of this policy, and outcome of claim:
05/09/1889: Claimed for damage to property during the Great Flood of ’89. Claim was rejected as damage was deemed to be from rain, not floodwater.
11/11/1892: Claimed for damage to property during bushfire. Claim rejected as premiums were not up to date.
17/02/1895: Claimed for post traumatic stress after being attacked by mad bullock. Claim investigated and rejected when body of bullock could not be produced.
27/01/1896: Claimed life insurance for spouse. Claim pending.
I certify to the best of my knowledge that the statements made above are true, correct and complete.
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