Liability Claim Form

Liability Claim Form

This form must be completed by the policy holder not the injured party. To be completed when accident causes damage to property or injury to a member of the public.
By submitting this form, you consent to the collection of your personal information for the purpose of assisting with your insurance claim and its disclosure to the relevant insurer to assess and manage your claim. Your information will be handled in accordance with the repX Privacy Policy.

To avoid delays in the assessment process, please submit the requested information as soon as possible.
Brokerage
Broker Email
If unknown, use info@remingtons.com.au
Claim Number (if known)
1. Details of Policy Holder
Name of Policy Holder
Please provide your registered company name if applicable
Address of Policy Holder

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation or Trade
Contact Details
First Name
Last Name
Email
example@example.com
Phone Number

Area or Mobile CodePhone Number
Insurer
Policy Number
Expiry Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate

Were there any witnesses?
Witness Details
State fully and clearly the circumstances surrounding the accident
3. ABN Details
Are you a registered business?
What is your ABN?
What percentage of GST in your premium did you claim as an Input Tax Credit for the period of insurance in which this loss occurred?
%

Declaration
I, {typeA223} {typeA224}, confirm that the information provided is true and correct to the best of my knowledge and understand it will be provided to the insurer to assist with my claim.
First Name
Last Name
Position
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Hour MinutesAM/PM Option
Signature
Should be Empty:

1. Details of Policy Holder