Public Liability Claim Form

Name of Insured:

Occupation:

Address:

Contact

Telephone:(Home)

Telephone:(Business)

Policy No.:

Renewal Date:

Date:

Time:

Place where accident occurred:

What work were you or your employess engaged to do ?

Details of how accident occurred ?

Name of addresses of witnesses(State if own employe or independent) ?

Name of addresses of person who, in your opinion, was to blame

Name of addresses of his/her employer if other than the Insured

If particulars were taken by the Police, give Number and Station of Officer taking details

Give details of any other polices covering you for this account.

Give name and address of possible claimant stating nature of injury or damage.

Have you received any claim? If so, from whom and in what form? If claim is in writing please forward with this form.

Please use this space to record additional detail and be sure to quote the question number from side one

I/We hereby declare the above particulars to be true and correct.

Contact Us