Public Liability Claim - Insurance Broker Melbourne

The supply or acceptance of this form is not an admission of liability on the part of the insurer.

Name*

First Last

Email*

Address

Street Address City State Post Code

Bus Phone

Private Phone

Fax

Occupation/Bus/Industry/Trade

Name any other interested party

How interested

Address

Street Address City State Post Code

Policy Number

Due Date

Is there any other Insurance in force which would cover this in whole or part.*

Yes
No

Please advise in the space provided.

Insurer’s Name

Policy Details

What is your Australian Business Number (ABN)?

Are you registered for GST?*

Yes
No

To what extent are you entitled to claim an Input Tax Credit on the GST applicable to the premium?

Date of Loss / Damage / or Occurrence

Time

:

When was it reported to you (if applicable)?

Time

:

Place and/or premises where it occurred

Please state full details of how loss/damage/or accident occurred

Please describe nature of damage or injury

Name and address of injured person or owner of damaged property.

Name	Address	Phone No.

Is the injured person or owner of damaged property in your employ, in the employ of any contractor or sub contractor to you, or related to you?

Yes
No

Please provide full details.

Has any claim been made against you?*

Yes
No

State full details and attach all communication received.

Did you admit liability in any way?*

Yes
No

Provide full details.

Have you any other information of which you consider the company should be aware?

Responsibility/Witnesses

In your opinion was any other person(s) responsible for loss or damage Or cause of the Occurrence?*

Yes
No

Please give full details.

Full Name

First Last

Address

Street Address City State Postal Code

Bus Phone

Private Phone

Fax Phone

Reason

Was there a witness or witnesses to this event?

Yes
No

Please give full details.

Witnesses

Name	Address	Bus Phone	Private Phone	Fax

Insurance History

Have you ever previously sustained loss/damage or caused damage or injury to 3rd parties?

Yes
No

Give details of such losses and amounts involved

Have you been convicted of or had any fines or penalties imposed for any criminal offences in the last 10 years?

Yes
No

Please provide details

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