Public Liability Insurance Claim 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 Business PhonePrivate PhoneFaxOccupation/Business/Industry/TradeName any other interested partyHow interestedAddress Street Address City State Post Code Policy NumberDue Date MM slash DD slash YYYY 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 NamePolicy DetailsWhat 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 / Occurrence DD slash MM slash YYYY Time : Hours Minutes AM PM AM/PM When was it reported to you (if applicable)? DD slash MM slash YYYY Time : Hours Minutes AM PM AM/PM Place and/or premises where it occurredPlease state full details of how loss/damage/accident occurredPlease describe nature of damage or injuryName and address of injured person or owner of damaged property.NameAddressPhone 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/WitnessesIn 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 Business PhonePrivate PhoneFax PhoneReasonWas there a witness or witnesses to this event? Yes No Please give full details.WitnessesNameAddressBusiness PhonePrivate PhoneFax Insurance HistoryHave you ever previously sustained loss/damage or caused damage or injury to 3rd parties? Yes No Give details of such losses and amounts involvedHave 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
