PUBLIC LIABILITY CLAIM FORM
   
INSURED

 
Name:    
Address: Occupation:
Cell: Telephone No:
Fax No: Email Address:
Id No: Vat No:
   
PARTICULARS OF ACCIDENT
Date and time of accident:
Place of accident
Exact place where accident occured
Explain exactly how the
accident happened
   
THIRD PARTY
Name of person injured Or
owner of property damaged
Address:
Age of person injured:
Details of injury:
Business or occupation:
Full details of personal injuries:
Damage of properties of
third parties
Have you made any offer to
settle the claim in any way?


   
OTHER INSURANCE
Have you any other
insurance in force in respect
of the occurrence?
If so, give particulars
   
PROPERTY OWNERS (TO BE COMPLETED ONLY IF CLAIM IN UNDER PROPERTY OWNERS POLICY)
Name and address of your
tennant
   
DRIVING ACCIDENTS (COMPLETE ONLY IF CLAIM UNDER A DRIVING
ACCIDENTS POLICY)
Name of driver :
Age:
Address:
How long has he been in
your employment?
Was the driver injured?


If so, give details
Description of vehicle
Was vehicle damaged?


If so, give particulars/cost of
repair
Where can vehicle be examined?
   
WITNESS
Name:
Address:
Telephone Number:
   
POLICE DETAILS (IF APPLICABLE)
 
 
PAYMENT METHOD
Name of bank:
Branch:
Account Holder:
Branch Code:
Type of account:
Account number:
   
DECLARATION
I/We solemnly declare that the above particulars are true in every respect.
   
Signature: