Liability Claim Form

Please click here for important information on The Liability Claim Form

1. Details Of Policyholder

Name & Address of Policyholder

Occupation or Trade

Telephone No: B/H

Telephone No: A/H

Email Address *

Insurer

Policy No

Expiry Date

GST Details: Are you registered for GST Purposes?

ABN No

To what extent are you entitled to claim an Input Tax Credit for this policy? (%)

2. Details Of Accident / Incident

Date of Accident

Time of Accident (am/pm)

Was there any personal injury?

If yes, please state: (i) name(s) and address(es) of injured persons:

Person 1 : Name

Address

Postcode

Person 2 : Name

Address

Postcode

Person 3 : Name

Address

Postcode

(ii) nature and extent of injuries:

(iii) name of doctor and/or hospital (if applicable)

Was any third party property damaged/stolen?

If yes, please state

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

(ii) phone number

Owner 1 : Name & Address

Postcode

Phone Number

Owner 2 : Name & Address

Postcode

Phone Number

Is the third party:

(i) an employee of the policyholder?

(ii) an employee of a sub-contractor?

(iii) a member of the policyholder’s family?

(iv) ordinarily resident in the policyholder’s home?

Have you been informed about the claim?

(i) verbally?

(If yes, to whom?)

(ii) in writing?

(If yes, please attach correspondence)

Name of your employee in charge at the time of the accident

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

Witness 1

Name

Address

Postcode

Witness 2

Name

Address

Postcode

Witness 3

Name

Address

Postcode

State fully and clearly the circumstances surrounding the accident/incident:

Did a Police Officer attend the accident/Incident?

If “yes”, Please state name of Police Officer, Police Station and Police Event Number

Did police lay any charges or advise action may be taken?

If yes, please supply full details

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”.

I/We agree: Yes No

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Liability Claim Form

Please click here for important information on The Liability Claim Form

1. Details Of Policyholder

2. Details Of Accident / Incident