General Liability Claim Form

General Liability Claim Form
Please complete your claim form so that we can get your claim moving!
Unfortunately the unexpected does happen!
This form collects personal information about you so that the insurer can evaluate your claim. Failure to provide this information may result in your claim being declined. The collection of this information is required as part of the terms of your insurance policy. It will be held by, your Appointed Brokerage and the insurer who received your claim. You have the rights of access to and correction of this information subject to the provisions of the Privacy Act 2020. Please visit our website to view our full Privacy Statement.
Your insured Name And/Or Company Name*
Please provide your registered company name if applicable
First Name*
Last Name*
Policy Number
Address*
Street Address
Street Address Line 2
City
Postal / Zip Code
Phone Number*
Area or Mobile CodePhone Number
E-mail*
example@example.com
Insured / Company name cannot contain “,*,:,,?,/,|, Please check your response

Claim Details
Tell us what happened?
Where did this happen*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
When did this happen?*
DayMonthYear
Date
Hour MinutesAM/PM Option
How did it happen?*
Please provide full details
Were there any witnesses*
YesNo
Witness Details*

Injury or Damage Details
Was the property under your care, custody or control?*
YesNo
Had you previously agreed to be responsible for any such damage?*
YesNo
Who owns the damaged property?*
Please provide full details
Was the damaged property insured?*
YesNoDon't know
Name of Insurance Company*
Have you done anything to reduce or make good on the loss or damage?*
YesNo
Details of actions taken*

Declaration
Declaration must be signed by the Policy Holder
I/We declare that to the best of my knowledge the details provided in this claim form are true. I/We have not withheld any information likely to affect the insurers consideration of the claim.
I/We agree to the appointed insurance brokerage and the Insurance Company (and/or their agent) with whom I am insured may disclose my/our personal information regarding this claim to:
1. Other parties including other members of the Insurance Industry and the data base of the Insurance Claims Register (ICR Ltd) PO Box 474, Wellington where it will be retained and made available to other insurance companies to inspect.
2. Parties who have a financial interest in the subject matter of the policy and parties repairing or replacing the subject matter of the claim.
3. I/We understand that I am/we are entitled to have certain rights of access to and correction of the personal information held by the appointed adviser and the Insurer and ICR Ltd.
4. I/We understand that my/our personal information may be provided to overseas third party service providers and/ or Insurers who may use this information either on our behalf or otherwise to process and evaluate the claim.
I/We agree to the appointed insurance brokerage and the Insurer obtaining personal information about me/us that is, in their view, relevant to this claim.
From any other party including other members of the Insurance Industry and from Insurance Claims Register Ltd (ICR) which holds details of claims made by me/us under policies with other insurers.
All information and answers (whether written or oral) given to the appointed adviser and the Insurance Company in connection with this claim are correct and that no information relevant to the claim has been omitted. I/We authorise the appointed brokerage and the Insurance Company to act on my/our behalf.
I {firstName} {lastName} am completing the declaration*
YesNo
First Name*
Last Name*
Position*
DirectorOwnerAuthorised Administrator
Date
DayMonthYear
Date
Hour MinutesAM/PM Option
Signature*
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General Liability Claim Form

Claim Details

Injury or Damage Details

Claimant Details

Declaration