Liability Claim Form

Please fill out all the fields below where applicable, providing as much detail as possible. This will help us to speed up the process of your Claim Form.

Policy Holder Details

Policy Number:
Name of Company:
Address:
Name:
Email:
Telephone:
VAT Registered?

Details of Incident

Date of Incident:	- -
Time of Incident:	:
Place:
Name of person involved:
Details of incident:
Was injured person an employee of yours at time of incident?
Accident Book Entry:
First Aid Report:
Supervisor's Report:
R I D D O Report (if applicable):
Report to DSS:
Form Completed By:
Form Completed Date:	17th May 2012