Public Liability Claim Form "*" indicates required fields 1INSURED2DETAILS3DECLARATION INSURERPOLICY NUMBERINSUREDNAME*OCCUPATION/ BUSINESSADDRESSTEL. NUMBERDESCRIPTION OF ACCIDENTDATE* DD slash MM slash 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 slash MM slash 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. 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 slash MM slash YYYY INSURED'S SIGNATURE*
