Public / Products Liability Incident Report Form
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2Public / Products Liability Incident Report
Liability
Commercial
The completion of this form is to report:
• Any accident which has caused bodily injury or property damage; or
• Any accident which has the potential to result in a personal injury or property damage claim.
If you have received any written communication, do not answer. Attach to this claim
Claim Number
Name of Insured:
Contact Person
Home Phone No.
Work Phone No.
Mobile No.
Email
Occupation
Postal Address
Postcode
Broker/Agent Name
Phone No.
Policy No.
Excess $
Inception Date
Expiry Date
■ ■
■ ■
G.S.T.: Are you registered for GST purposes?
Yes
No
A.B.N.
To what extent are you entitled to claim an Input Tax Credit on the GST for this policy?
%
■ ■
■ ■
■ ■
■ ■
Premises Leased?
Yes
No
Have premises been altered since Incident?
Yes
No
If yes, give details
Incident / Accident: Date
Time
am/pm Date Reported
Location
Purpose for which location was being used
■ ■
■ ■
Who was incident reported to?
Employee Yes
No
Describe the Incident (including the cause and source of information)
Products Liability: (If applicable, please complete the following)
Product Name
Model No.
Serial No.
Lot No.
Batch No.
Customer’s Name
Phone No.
Address
Postcode
Allianz Australia Insurance Limited AFS Licence No. 234708 ABN 15 000 122 850 Registered Office: 2 Market Street Sydney NSW 2000
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Parent category: Business