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Liability Claim Form

1. Details Of Policyholder

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2. Details Of Accident / Incident

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

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(ii) nature and extent of injuries:

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

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If yes, please state

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

(ii) phone number

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Is the third party:

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Have you been informed about the claim?

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

Witness 1

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Witness 2

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Witness 3

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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”.

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