Saturday, 19 May 2012
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Liability Claim Form

  1. 1. Details Of Policyholder

  2. Name of Policy Holder
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  3. Address of Policy Holder
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  4. Occupation or Trade
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  5. Telephone No: B/H
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  6. Telephone No: A/H
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  7. Email Address(*)
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  8. Insurer
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  9. Policy No.
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  10. Expiry Date
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  11. GST Details: Are you registered for GST Purposes?
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  12. ABN No
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  13. To what extent are you entitled to claim an Input Tax Credit for this policy? (%)
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  14.  

  1. 2. Details Of Accident / Incident

  2. Date of Accident
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  3. Time of Accident (am/pm)
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  4. Was there any personal injury?
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  5. If yes, please state: (i) name(s) and address(es) of injured persons:

  6. Person 1 : Name
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  7. Address
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  8. Postcode
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  9. Person 2 : Name
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  10. Address
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  11. Postcode
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  12. Person 3 : Name
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  13. Address
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  14. Postcode
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  15. (ii) nature and extent of injuries:

  16. 1.
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  17. 2.
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  18. 3.
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  19. (iii) name of doctor and/or hospital (if applicable)

  20. Doctor &/or Hospital details
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  21. Was any third party property damaged/stolen?
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  22. If yes, please state

    (i) name(s) and address(es) of owner(s)

    (ii) phone number

  23. Owner 1 : Name & Address
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  24. Postcode
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  25. Phone Number
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  26. Owner 2 : Name & Address
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  27. Postcode
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  28. Phone Number
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  29. GST Details: Are you registered for GST Purposes?
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  30.  

  1. Is the third party:

  2. (i) an employee of the policyholder?
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  3. (ii) an employee of a sub-contractor?
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  4. (iii) a member of the policyholder’s family?
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  5. (iv) ordinarily resident in the policyholder’s home?
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  6. Have you been informed about the claim?

  7. (i) verbally?
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  8. (If yes, to whom?)
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  9. (ii) in writing?
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  10. (If yes, please attach correspondence)
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  11. Name of your employee in charge at the time of the accident
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  12.  

  1. Give details of all witnesses and their relationship(ie, employer, family, etc):

  2. Witness 1

  3. Name
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  4. Address
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  5. Postcode
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  6. Witness 2

  7. Name
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  8. Address
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  9. Postcode
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  10. Witness 3

  11. Name
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  12. Address
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  13. Postcode
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  14. State fully and clearly the circumstances surrounding the accident/incident:
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  15. Did a Police Officer attend the accident/Incident?
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  16. If “yes”, Please state name of Police Officer, Police Station and Police Event Number
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  17. Did police lay any charges or advise action may be taken?
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  18. If yes, please supply full details
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  19.  

  1. DECLARATION

    I declare that the above statements are true, that I have not suppressed or mis-stated any facts . I expressly agree that the information given by me is provided with my full knowledge and consent and further agree to hold harmless and indemnify Action Insurance Brokers Pty Ltd, its Employees and Representatives in the event of any action or matter that may be taken by any party pursuant to the Privacy Act 1988 (Cth). I/We acknowledge that I/we have read and understood the paragraphs accompanying this proposal headed “Your Privacy”.

  2. I/We agree with the above statement(*)
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  3. Submit