Liability Claim Form - Ssaa Insurance Brokers
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4SSAA Insurance Brokers Pty Ltd
Phone
(08) 8332 0281
The Precinct
Freecall
1800 808 608
Suite 14, 539 Greenhill Road
Facsimile
(08) 8332 0303
539 Greenhill Road
Email
.au
Hazelwood Park SA 5066
Web
Liability Claim Form
No admission of liability, either implied or expressed, should be made. Any claim made
upon you should simply be acknowledged with advice that the matter has been referred to
your insurer for determination. The completion of this form and its receipt is not an indication
that your Insurer accepts any liability to you or to any person claiming from you.
Note: This form must be completed by the policyholder NOT the injured/third party
If there is not enough room on this form for your answers, please attach a separate
sheet, indicating the Section and Question you wish to complete.
Your Privacy
Further information about how to access the personal information
The Privacy Act 1988 requires us to make the following disclosure
we hold about you, have it updated or corrected or how to make a
before collecting personal information about you:
complaint about how your personal information is collected or
used is in our Privacy Policy on our website:
We collect personal information in order to provide our
broking services including assistance with insurance claims.
We will ask you to supply personal information on this form so
CONTACT US
we can assist you to submit your insurance claim and have it
You can contact our Privacy Officer using the details below:
considered by the insurer. We will disclose this information to
the insurer for this purpose.
The Precinct
Phone (08) 8332 0281
Suite 14, 539 Greenhill Road
Facsimile 08 82119838
If the personal information is not provided, the insurer may
Hazelwood Park SA 5066
.au
not be able to assess and pay the claim and we may not be
able to assist with your claim.
We and the insurer may disclose the personal information to
other people involved in reviewing the claim, including
reinsurers, other insurance intermediaries, the insurer’s
advisors such as loss adjusters, lawyers and accountants, and
other parties involved in the claims handling process.
By signing this form you consent to us and the parties
mentioned above collecting, using and disclosing personal and
sensitive information about you for the purposes described
above.
You understand that any personal and sensitive
information disclosed to organisations located overseas may
not be protected in the same way as it is in Australia. Even
though we have no control over how the information will be
used and disclosed, you consent to us disclosing your personal
and sensitive information to those overseas organisations for
the purposes described above.
SSAA Insurance Brokers Pty Ltd | ABN 86 077 822 970 | Corporate Authorised Representative No 315403 for:
Westcourt General Insurance Brokers Pty Ltd | ABN 81 009 401 772 | AFSL 238447
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Parent category: Legal