Public Liability Claim Form

Public Liability Claim Notification Form

Simply fill out the claim notification form below and one of our claims specialists will be in contact with you shortly.

Fields marked with an * are required

Please indicate if you are the broker or the policy holder *

BrokerPolicy Holder

Broker First Name *

Broker Last Name *

Broker Email Address *

Insured Client Code (WinBEAT or Insight) *

Insured's Details

Name of Insured (other than trading name)

Trading name of business

Policy number (from schedule)

Address

Telephone Number

Mobile Number

Email Address

Indemnity sought

Yes No

Indemnity being sought as you have received a claim for loss or action against you.

Notification Only

YesNo

A notification is when an insured discloses the facts that might give rise to a claim.

Are you registered for GST purposes?

YesNo

What is your Australian Business Number?

What percentage of the GST on the policy premium were you entitled to claim as an Input Tax Credit (%)?

Claim Details

Claimant Name

Claimant Email Address

Claimant Phone Number

Date of Incident

Time of Incident (please specify AM/PM)

Address where the incident happened

Please describe fully how the loss / damage occurred

Is there a Letter of Demand?

YesNo

Please attach a copy of the document

Browse

Have you received a Statement of Claim or any other correspondence from the Courts?

YesNo

Please attach a copy of the document

Browse

Are there any other files relating to this incident that you would like to upload?

YesNo

File 1

Browse

File 2

Browse

File 3

Browse

File 4

Browse

File 5

Browse

File 6

Browse

Additional Details

Witness Information

Were there any witnesses?

YesNo

Witness No.1

Full Name

Phone Number

Address

Witness No.2

Full Name

Phone Number

Address

General Information

Did the police attend?

YesNo

Please provide details

Are there any incidents in similar circumstances?

YesNo

Please provide details

Do you consider yourself responsible for the incident?

YesNo

State reason

Name and address of person(s) whom you consider to be responsible and their relationship to you

Injured person(s) details

Was anyone injured from this incident?

YesNo

Name

Address

Full details of injuries

What is your relationship to the person?

Property damaged details

Was there any damage to property?

YesNo

Name of the owner(s) of the property damaged

Address of property

What is your relationship to the owner(s)?

Describe the property and the full details of damage (if a vehicle, please include make, model and registration)

Estimated cost of repair/replacement

Was the property in your custody?

YesNo

For what purpose?

Have any repairs been carried out?

YesNo

Name of repairer

Address of repairer

Cost of repairs

Importance Notice

No admission of liability, either implied or expressed, should be made. Any claim made upon you should simply be acknowledged with advice that the matter has been referred to your insurer for determination. The completion of this form and its receipt by Coverforce is not an indication that the Insurer accept any liability to you or to any person claiming from you.

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