New Claim Report - Liability

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Liability

* Required information.

Insured name *

Phone Number - Home *

Phone Number - Business

Moblile Phone Number

Date of occurrence *

Time *

AM or PM *

Exact place of occurrence *

Suburb *

State *

Postcode *

Name of person(s) injured or owner(s) of property lost/damaged *

Address *

State exactly what happened and how it occurred *

Did you admit liability in any way? *

Witness/es Name

Address of witness

Any estimate available for damaged property? *

State nature of personal injuey or loss or damage sustained *

Has a report of personal injury and/or personal damage been made *

Yes

If yes, by whom and when

Have you any other information of which you consider we should be made aware of

Have any claims been made on you either verbally or in writing *

Yes

Date *

Name of person lodging report *

I agree that upon submission the information provided is true and correct. *

I agree

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