1800-0-ACTION
1800-0-228-466
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
2. Details Of Accident / Incident
If yes, please state: (i) name(s) and address(es) of injured persons:
(ii) nature and extent of injuries:
(iii) name of doctor and/or hospital (if applicable)
If yes, please state
(i) name(s) and address(es) of owner(s)
(ii) phone number
Is the third party:
Have you been informed about the claim?
Give details of all witnesses and their relationship(ie, employer, family, etc):
Witness 1
Witness 2
Witness 3
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”.
© Copyright AIBG P/LABN 39 080 844 426 AFS 225047 Privacy PolicyFamily Violence Policy Disclaimer Sitemap Site by : I'm The Black Sheep
Get a Quote Make a Payment Make a ClaimFinancial Services Guide Insurance Product Fact Sheets About Us Community Support Latest News
Bella Vista NSW Penrith NSW Parramatta NSW Robina, QLD