Public Liability Claim "*" indicates required fields 1INSURED2DETAILS3BANKING DETAILS 4DECLARATION INSURERPOLICY NUMBERYour Email Address Please enter your email if you would like a copy.INSUREDNAME*OCCUPATION/ BUSINESSADDRESSTEL. NUMBERDESCRIPTION OF ACCIDENTDATE* DD dash MM dash YYYY Time Hours : Minutes AM PM AM/PM PLACE WHERE INCIDENT / ACCIDENT OCCURREDSTATE EXACTLY HOW THE INCIDENT / ACCIDENT OCCURREDWITNESSNAMETELEPHONE NUMBERADDRESSDESCRIBE FULLY HOW THE LOSS OR DAMAGE OCCURRED*HAVE YOU PREVIOUSLY SUFFERED A LOSS / DAMAGE?*NoYesDETAILS OF SUFFERED A LOSS / DAMAGE? POLICEPOLICE REF. NO.*POLICE STATION*DATE REPORTED DD dash MM dash YYYY PROPERTY DAMAGENAME OF OWNERADDRESS OF OWNERDESCRIPTION OF DAMAGEPERSONAL INJURIESNAME OF INJURED PERSONAGE OF INJURED PERSONADDRESS OF INJURED PERSONDETAILS OF INJURIESIF PERSON NAME ABOVE IS IN YOUR SERVICE, OR YOUR TENANT, OR RELATED TO YOU, GIVE FULL DETAILS.IF CLAIM MADE AGAINST YOU GIVE DETAILS AND ATTACH ANY CORRESPONDENCEFile Drop files here or Select files Max. file size: 256 MB. IT IS RECOMMENDED THAT ANY AMOUNT PAYABLE TO YOU DIRECT BE TRANSMITTED BY ELECTRONIC BANK TRANSFER / DEPOSIT OF CHEQUE FOR SPEEDIER SETTLEMENT AND SECURITY REASONS. IF YOU ARE AGREEABLE TO THIS, PLEASE PROVIDE THE FOLLOWING INFORMATION. NAME OF BANKBRANCH CODE NUMBERNAME OF ACCOUNT HOLDERACCOUNT NUMBER I / WE SOLEMNLY DECLARE THAT I / WE HAVE SUFFERED LOSS OF OR DAMAGE TO THE PROPERTY ENUMERATED ABOVE AND THAT THE SAID PROPERTY WAS IN MY / OUR POSSESSION IMMEDIATELY PRIOR TO THE SAID LOSS / DAMAGE WHICH OCCURRED IN THE CIRCUMSTANCES DESCRIBED ABOVEDATE DD dash MM dash YYYY INSURED'S SIGNATURE*
