Public / Products Liability Incident Report Form Page 2
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1
2Property Damaged:
Nature and extent of damage
Estimated Cost $
Name of Owner of damaged property
Address
Postcode
Phone No. (Home)
Phone No. (Work)
Mobile No.
Personal Injury:
Name of Person Injured
■ ■
■ ■
Age
years
Sex
Male
Female
Occupation
Address
Postcode
Phone No. (Home)
Phone No. (Work)
Mobile No.
Nature of Injury
■ ■
■ ■
Was treatment given at the scene of the Incident?
Yes
No
If Yes, by whom (if ambulance or doctor, give details)
Address
Postcode
■ ■
■ ■
Was transport provided to hospital?
Yes
No
■ ■
■ ■
Witnesses: Were there any witnesses to the event? Yes
No
(If yes, please complete the following)
Name
Address
Postcode
Phone No. (Home)
Phone No. (Work)
Mobile No.
Where was the Witness?
Second Witness:
Name
Address
Postcode
Phone No. (Home)
Phone No. (Work)
Mobile No.
Where was the Witness?
Privacy: The Privacy Act 1988 requires us to tell you that
external claims data collectors, investigators and agents
as an insurer we collect your personal and sensitive
or other parties as required by law.
information in order to calculate your loss and
You have the right to seek access to your personal
entitlements, determine our liability, compile data and
information and to correct it at any time. Please contact
handle claims. When handling claims, we may have to
us on 1300 360 529 EST 9am-5pm, Monday-Friday and
disclose your personal and other information to third
advise us of the changes.
parties such as other insurers, reinsurers, loss adjusters,
IDR Statement: Disputes are not an everyday
If you are not satisfied with the outcome of this process,
occurrence at Allianz. However we do provide an
we will advise you how to contact the insurance
internal dispute resolution process should any dispute
industry’s external independent complaints scheme
arise. Please feel free to ask for details.
(subject to eligibility).
Declaration: I/We certify that the information given in
consent to the collection, storage, use and disclosure of
this form is truthful, accurate and complete. No
personal and sensitive information of all persons
information likely to affect this claim has been withheld.
affected by this claim, with their approval. I/we
I/We understand that this claim may be refused if
acknowledge that if I/we do not agree to the collection
information is untrue, inaccurate or concealed.
of this personal and sensitive information then Allianz
will be unable to process my/our claim.
I/We acknowledge that I/we have read and understood
the Privacy Act 1988 information referred to above and
Signature of Insured
Date
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