Liability Claim Form

Your Details

Name*

Business Name / Name of Insured

Policy Number

Phone Number*

Email*

Third Party Details

Name of Third Party/ies involved in the Loss*

Third Party/ies details*

How is this party involved?*

Details of Loss

What date/s did the specific incident occur?*

What date/s did you become aware that this matter could be a circumstance or a claim?*

Location where the loss occurred?*

Please provide full details of the loss explaining what happened and how it occurred*

Type of Loss

Was the type of loss*

Bodily injury only
Property damage only
Both bodily injury & property damage

Bodily Injury Incident

Briefly describe the type of injury sustained*

Was medical treatment provided?*

Yes
No
Unsure

If yes, by who?

Was transportation used?*

Yes
No
Unsure

If yes, was it by ambulance or similar para-medical vehicle?*

Yes
No
Unsure

Property Damage Incident

Briefly describe the type of property damaged*

Briefly describe the nature and extent of the damage*

What is the approximate cost of the damage suffered?*

Has the property been repaired?*

Yes
No
Unsure

Please provide details where possible*

Witnesses

Were there any witnesses?*

Yes
No
Unsure

Please provide full details of persons who witnessed the loss, incident &/or circumstance*

Regulatory &/or Other Authorities

Has this loss been reported to any regulatory &/or supervising authority (eg Police, Workcover, EPA, etc)?*

Yes
No
Unsure

If yes, please provide further details*

Further Documentation

Please attach any relevant documentation for this matter or email your broker directly once this form has been submitted

Drop files here or

Max. file size: 32 MB.

This includes Letters of Demand, correspondence from third parties, quotes for repairs, relevant contracts, agreements etc

Declaration

Please tick to confirm the following to declare:*

The information provided is true and correct
No information has been intentionally withheld
Acknowledge that the completion of this form does not automatically mean that indemnity for this loss has been granted

Signature

This electronic signature will be treated the same as if signed personally.

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