NAB Traveller Card
Dispute Claim Form
This form will be returned if incomplete, or supporting documentation is not supplied
Please complete the form in full and return it to us by post, email or fax to the details given below. If we do not receive the form
within 30 days, we assume you no longer wish to proceed with the dispute and your case will be closed
Post: Card Services, NAB Traveller Card, PO Box 1653, North Sydney NSW 2060
Email:
[email protected]Fax: +61 (0)2 8244 8336
Completing this form
ATM: If your dispute relates to an ATM not paying out the correct amount you requested, please only complete Section 1, 2 and 6 of
this form.
ALL OTHER DISPUTES: For all other disputes, please complete the form in full.
Section 1: Your personal details
Cardholder Name
Cardholder Address
Card Number
Contact Phone Numbers Home
Mobile
Temporary
Email Address
Section 2: Details of dispute
Transaction Date Merchant Name / ATM Transaction Reference Number Amount & Currency
Location
Please continue on the reverse of this form or another sheet if necessary
Section 3: Card details
Was the card signed? Yes / No
Where did you last use the card?
What date and time did you last use the
card?
Is the card still in your possession? Yes / No
Do you keep a written copy of your PIN? If Yes / No
yes, please provide details
Could your PIN be known to other persons? Yes / No
If yes, please provide details
Do you know the person who did these Yes / No
transactions? If yes, please provide details
NAB Traveller Card
Dispute Claim Form
Section 4: Complete if card is NOT in your possession
How has the card come to be out of your Lost / Stolen / retained in ATM / Not received in post / other (provide details)
possession?
Please provide details of date and time:
What other documents or personal
property was lost or stolen at the same
time?
Section 5: Complete if card is in your possession
What is the expiry date of the card?
Have you ever given your card details to a third party? Yes / No
If yes, please provide details of who, when and the reason
Have you ever used your card at any of the merchants where you Yes / No
are disputing the transactions?
If yes, please provide details of your transactions and attach supporting
documents such as receipts
Have you ever visited the country where the disputes took place? Yes / No
If yes, please provide details
If the transactions happened after you had left the country, please provide
travel related documents to show this
When was the last time you used your card?
Please provide details of date, time, merchant name and location
Have you ever knowingly allowed somebody else to use your Yes / No
card?
If yes, please provide details
Have you ever entered your card details on the Internet? Yes / No
If yes, please provide details including anyone else who has access to
your computer
Please include any free services or subscriptions you have signed up for
Have you contacted the merchant in the attempt to resolve this Yes / No
issue?
If yes, please provide supporting documents showing details including
dates, method of contact and response from the merchant
NAB Traveller Card
Dispute Claim Form
Section 6: Details and declaration
Please provide the full circumstances surrounding your claim in the space below (you may use the reverse form, or another sheet if
necessary):
Have you informed the Police and/or your insurers? Yes / No
If yes, please provide details and attach supporting documents:
If no, please explain why:
Declaration
I, the undersigned, declare that all information contained within this statement is correct to the best of my knowledge. I
understand that the information I have provided will be transmitted across national borders, will be used in undertaking
possible fraud investigations, and may be passed to law enforcement agencies.
Signed:
Print Name:
Date:
When you have completed the form, please sign and return it to us by post, email or by fax to the details given below
Post: Card Services, NAB Traveller Card, PO Box 1653, North Sydney NSW 2060
Email: [email protected]
Fax: +61 02 8244 8336
