CLAIM/INCIDENT NOTIFICATION
PROPOSER
Name
T/as
Address
P/Code
CONTACT DETAILS
Tel
Fax
Mob
Email
Web
YOUR POLICY
What Policy Is The Claim Against
Policy Type
Insurer
Policy Number
Next Renewal Date
THE INCIDENT
Date Of Incident
Time Of Incident
Date First Reported To You
Describe the incident, injury, material damge and full circumstances..
CLAIMANT DETAILS
(1)
Name
T/as
Address
P/Code
Tel
Email
Relationship
How are they involved
(2)
Name
T/as
Address
P/Code
Tel
Email
Relationship
How are they involved
(3)
Name
T/as
Address
P/Code
Tel
Email
Relationship
How are they involved
(4)
Name
T/as
Address
P/Code
Tel
Email
Relationship
How are they involved
WITNESS DETAILS
(1)
Name
Address
P/Code
Tel
Email
What did they witness
(2)
Name
Address
P/Code
Tel
Email
What did they witness
MATERIAL DAMAGE
What damage has occurred and cost?
Damage
Value
Total Value (The Claim)
Insurers will require proof of ownership and estimates of loss in formal statement of claim
CONDITIONS
IMPORTANT Please do not enter into any correspondence with any injured party/employee or his/her representatives. Similarly no payments, offers or admission of liability are permitted by your policy. Any such action could prejudice the insurers position adversely. It is a condition of insurance that any accident/loss which may result in a possible claim must be reported immediately. Late notification must be accompanied with a letter of explanation for any late notification. Insurance companies maintain a number of anti-fraud and theft registers to help check information and prevent fraudulent claims. Insurers may search these registers as part of their investigations and will pass information relating to this incident to the appropriate register(s) for the future reference of other parties. In addition to this form your insurers may wish to speak directly to you or appoint Loss Adjusters to further investigate the circumstances of the incident reported. You must provide copies of any correspondance and/or photographs as applicable.
These are important. Tick that you understand.
OTHER INFORMATION
Telephone 02870325999 for assistance