General Liability Claim Form

General Liability Claim Form

Please ensure you complete the form with as much detail as possible
1. Insured or Company Details
Insured Name *
Policy Number
Phone Number *

Area Code Phone Number
E-mail *
Are you Registered for GST *

Yes No
Do you have an ABN *

Yes No
If Yes, ABN Number
2. Claim Details
Date/Time of Incident *

Day Month Year
Date Hour Minutes AM/PM Option
Who reported the incident?
Date you first became aware of the incident *

Day Month Year
dd-mm-yyyy
Address of Incident *

Street Address

Street Address Line 2

Suburb State

Post Code Country
Please provide full details of how loss/damage occurred *
Has the claim been reported to the Police? *

Yes No
If yes please provide Police Report No.
Have you or your employees, contractors or subcontractors admitted liability in any way? *

Yes No
If yes, please provide details
3. Third Party Details
Name of person *
Address *

Street Address

Street Address Line 2

Suburb State

Post code
Email *
example@example.com
Phone Number *

Area Code Phone Number
Third party insurance policy number (if known)
4. Property Damage Details
Name of the owner of the property damaged *
Address *

Street Address

Street Address Line 2

Suburb State

Post Code
Please provide description of damaged property
Was the property in your custody *

Yes No
If yes, for what purpose?
Have any repairs been carried out? *

Yes No
If yes, provide details - Name of Repairer
Address

Street Address 1

Street Address 2

Suburb State

Post Code
Repairer Phone No

Area Code Phone Number
Approximate cost of repairs *
Declaration
Signature

Clear
Name

First Name Last Name
Date & Time
Please upload any files to assist with this claim

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General Liability Claim Form

1. Insured or Company Details

2. Claim Details

3. Third Party Details

4. Property Damage Details

Declaration