Liability Claim Form for Property Damage with Motor Vehicles Involved

Insured Details

Name of the insured*

Trading Name

Policy Number*

ABN*

Are you Registered for GST?

Yes

Input Tax Credit Entitlement %

Name of the person providing information*

Phone Number of the Person Providing Information*

Email*

Occupation Details*

Incident Details

Date of Incidence*

Time of Incidence*

Location of Incidence*

Incidence Details*

Motor Vehicle Involved in the Incidents

Were there any motor vehicles involved in the incident?*

Yes

Vehicle Details

Make

Model

Year

Engine No.

VIN No.

Rego No.*

Was the vehicle moving or stationary?*

Moving

Stationary

Driver's Full Name*

Date of Birth*

Type of License*

Year License Obtained*

Email Address

Contact Phone Number*

Add more

Property Damaged

Please provide full details of your loss (to avoid delays in processing your claim, please attach all original repair invoices, receipts or replacement quotes to this form. Proof of ownership is required for stolen or lost items i.e. purchase invoices, receipts, valuations, operating manuals, etc.)*

Description of property damaged/stolen/lost

Year Purchased

Replacement Value

Cost of Repairs

Amount Claimed

Responsible Party

In your opinion, who is responsible for the incidence?

Insured or their Employee

Contractor or Sub-contractor

Third party

No one

Full Name*

Address

Phone*

Email Address

Witness Details

Were there any witnesses to the incident?

Yes

Witness Details

Witness Name*

Witness Address*

Witness Phone Number*

Witness Email Address*

Add more

Party Claiming Against You

Full Name*

Address

Phone Number*

Email Address*

If You Need to Provide More Details

More Details

Documents Attached

Photos of the incident

Yes

Quotes

Yes

Liability Claim Form for Property Damage with Motor Vehicles Involved

Insured Details

Incident Details

Motor Vehicle Involved in the Incidents

Property Damaged

Responsible Party

Witness Details

Party Claiming Against You

If You Need to Provide More Details

Documents Attached

Declaration

If Existing Business

Insured Details

Director/ Owner

Policy

Duty Of Disclosure

If Existing Business

Insured Details

Director/ Owner

Policy

Duty Of Disclosure

Liability Claim Form for Property Damage with Motor Vehicles Involved

Insured Details

Incident Details

Motor Vehicle Involved in the Incidents

Property Damaged

Responsible Party

Witness Details

Party Claiming Against You

If You Need to Provide More Details

Documents Attached

Declaration

If Existing Business

Insured Details

Director/ Owner

Policy

Duty Of Disclosure

If Existing Business

Insured Details

Director/ Owner

Policy

Duty Of Disclosure

This questionnaire should be completed in conjunction with the ISP Proposal Form. When completed, please sign this questionnaire where indicated, ensuring that prior to signing you have read and understand Your Duty of Disclosure and our Privacy statement.

Section A: General Information

Section B: Machines to be insured

The age of the pumping unit must be supplied

Truck

Pump

Section C: Maintenance And Accreditation

Who undertakes maintenance / servicing of concrete pumping machines?

Section D: Claims and/or circumstances

Who undertakes maintenance / servicing of concrete pumping machines?

Your duty of disclosure

QBE Privacy

UAA Privacy

Declaration

General Information