Public Liability Insurance Claim Form

Insured Name*

Email*

Phone Number*

Policy number*

Insurance Product*

Details of incident

Date of loss*

Time of loss*

When was it reported to you?*

Place and/or premises where it occurred.*

Please describe nature of damage or injury.*

Name, address and contact number of injured person or owner of damaged property*

Is the injured person or owner of damaged property in your employ, in the employ of any contractor or sub contractor to you, or related to you? (if YES please provide details)*

Has any claim been made against you? (if YES please provide details)*

Did you admit liability in any way? (if YES please provide details)*

Was there a witness or witnesses to this event? (if YES please provide details)*

Insurance history

Please list description, sum claimed and purchase date of each item*

Total sum claimed*

Insurance history

Have you had any claims in the last 5 years? (YES / NO If Yes, provide details.)*

Has any Insurance Company refused to renew or cancelled/terminated a policy? Has any Insurance Company refused a claim? (YES / NO If Yes, provide details.)*

Have you been convicted of or had any fines or penalties imposed for any criminal offences in the last 10 years? (YES / NO If Yes, provide details.)*

Additional information (optional)

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