AiS Insurance Pty Ltd - Specialising in Service - Member of Steadfast Group Limited

New Claims Report - Liability:

Insured name :
Phone Numbers - Home
Business:
Mobile:
Date of occurrence:
Time:
AM/PM:
Exact place of occurrence:
Suburb:
State:
Post Code
Name of person(s) injured or owner(s) of property lost/damaged :
Address:
State exactly what happened and how it occurred:
Did you admit liablity in any way? - Yes/No
Witness/es Name:
Address:
Any estimate available for damaged property: - Yes/No
State nature of personal injury or loss or damage sustained:
Has a report of personal injury and/or personal damage been made to you by a third party claimant: - Yes/No
If yes by whom and when:
Have any claims been made on you either verbally or in writing? - Yes/No
Have you any other information of which you consider we should be made aware of?
Date:
Name of person lodging report: