Liability Claim Form

Page 1 of 5

Please click here for important information on the Liability Claim Form

Please click here to download a hardcopy of the Liability Claim Form

1. Details Of Policyholder

Name of Policy Holder

Invalid Input

Address of Policy Holder

Invalid Input

Occupation or Trade

Invalid Input

Telephone No: B/H

Invalid Input

Telephone No: A/H

Invalid Input

Email Address(*)

Invalid Input

Insurer

Invalid Input

Policy No.

Invalid Input

Expiry Date

Invalid Input

GST Details: Are you registered for GST Purposes?

Invalid Input

ABN No

Invalid Input

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

Invalid Input

2. Details Of Accident / Incident

Date of Accident / Incident

Invalid Input

Time of Accident / Incident (am/pm)

Invalid Input

Where did the accident/incident take place

Invalid Input

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

Invalid Input

Was there any personal injury?

Invalid Input

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

Person 1 : Name

Invalid Input

Address

Invalid Input

Postcode

Invalid Input

Person 2 : Name

Invalid Input

Address

Invalid Input

Postcode

Invalid Input

(ii) nature and extent of injuries:

Invalid Input

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

Doctor &/or Hospital details

Invalid Input

Was any third party property damaged/stolen?

Invalid Input

If yes, please state

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

(ii) phone number

Owner 1 : Name & Address

Invalid Input

Postcode

Invalid Input

Phone Number

Invalid Input

Owner 2 : Name & Address

Invalid Input

Postcode

Invalid Input

Phone Number

Invalid Input

GST Details: Are you registered for GST Purposes?

Invalid Input

Is the third party:

(i) an employee of the policyholder?

Invalid Input

(ii) an employee of a sub-contractor?

Invalid Input

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

Invalid Input

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

Invalid Input

Have you been informed about the claim?

(i) verbally?

Invalid Input

(If yes, to whom?)

Invalid Input

(ii) in writing?

Invalid Input

(If yes, please attach correspondence)

Invalid Input

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

Invalid Input

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

Witness 1

Name

Invalid Input

Address

Invalid Input

Postcode

Invalid Input

Witness 2

Name

Invalid Input

Address

Invalid Input

Postcode

Invalid Input

Witness 3

Name

Invalid Input

Address

Invalid Input

Postcode

Invalid Input

Did a Police Officer attend the accident/Incident?

Invalid Input

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

Invalid Input

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

Invalid Input

If yes, please supply full details

Invalid Input

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 with the above statement(*)

YesNo

Invalid Input

Anti-Spam(*)

Invalid Input

Submit

Liability Claim Form

Company Information

Insurance Products

Services

Contact Us