Kimberley floods customer assistance form

All fields are required unless marked as optional

Relationship to account

I am a Property owner Tenant or lessee Managing agent Other

First name

Last name

Phone number

Email address

Account number (optional)

Property address

Suburb

Postcode

Is this property a home or business address? Home Business

Are you able to live in your home? Yes No

Where are you currently residing?

Please provide details of any damage you’ve experienced and/or the assistance you require

Do you currently have a direct debit with us? Yes No

Preferred contact method Email Phone