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Public Liability Accident Claim |
No 2 The Colosseum Building Century City
PO Box 90 Century City 7446 |
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| Insured | ||||
| Name | ||||
| Surname | ||||
| Address | ||||
| Telephone | ||||
| Fax | ||||
| Occupation | ||||
| Policy Number | ||||
| Description of accident | ||||
| Date and time | ||||
| Place where accident occurred | ||||
| State exactly how the accident occurred | ||||
| Notification of previous accidents | ||||
| Has any circumstance which might give rise to a claim been notified to any of your previous insurers? | Yes No | |||
| If yes, please give full details, including dates and names of insurers | ||||
| Witnesses | ||||
| Name, address and telephone numbers of any witnesses | ||||
| Police | ||||
| If reported to police, state which station and refernce number | ||||
| Property damage | ||||
| Name of owner | ||||
| Address of owner | ||||
| Description of damage | ||||
| Personal injuries | ||||
| Name of injured person | ||||
| Address of injured person | ||||
| Age of injured person | ||||
| Relationship | ||||
| If person above is in your service, your tenant or related to you, give full details | ||||
| Claim | ||||
| If claim made against you, give details and fax any correspondence to us | ||||
| Signature | ||||
| Name | ||||
| Signature | ||||
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| Please print the completed
form and fax the signed document to 0865 202 355 |
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