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LIABILITY CLAIM FORM

Accordance with the conditions of the Policy under no circumstances should liability be admitted or any offer of settlement be made without the prior written consent of New India Assurance.

This form must be completed by a person authorized to do so on behalf of the Policyholder/ Insured.

All questions must be answered as fully as possible (use additional pages if necessary)

Policyholder(s) / Insured Details

Full Name:*

Address:*

Contact Details:

Telephone:

Work:

Home:

Mobile:

E mail:

Policy Details

Policy Type

Public Liability

Employers Liability

Statutory Liability

Carriers Liability

Policy Number :

Limit of Indemnity: $

Excess: $

Third Party Details

Claimant Name:

Does the Claimant have a direct or indirect financial interest in you?

Yes

Is the Claimant related to you in any other way?

Yes

If yes, to either of the above question, please explain.

Relevant Dates

Date accident/possible error occurred giving rise to complaint, claim or possible claim*

Date complaint, claim or intimation of claim first made

Date Insured first became aware of complaint, claim or possible claim

If you were aware of the existence of a complaint, claim prior to insuring with New India Assurance Co. Ltd, have you advised the previous insurer?

Yes

Past Losses and Current Claims

Please list below all losses or circumstances (whether or not resulting in claims) paid or outstanding during the past five years:

Year of Loss	Description of Loss	Amount Paid	Amount Outstanding
		$	$
		$	$
		$	$
		$	$
		$	$
		$	$

Nature Of Claim Or Circumstance

Explain the background events giving rise to complaint, claim or possible claim. Please attach copies of supporting correspondence and /or documentation Please refrain from offering any view about fault, blame or liability.

Quantum at issue

Amount of claim or estimate of claimant’s alleged loss:$

Your Privacy

We collect and receive your personal information in this claim form to consider your claim. We Act 1993.

You must provide your relevant personal information to us to comply with the Claims Conditions of this policy. If you fail to do so, we may decline your claim.

We obtain your authority below to transfer your relevant personal information to other members of the insurance industry (including Insurance Claims Register Limited), financially interested parties noted on your policy, and repairers.

Your Declaration

I / We declare that to the best of my/our knowledge and belief these particulars are complete and correct and I/we have not withheld or miss-stated any material information which may directly or indirectly affect this claim.

I / We
(i) Agree to give any further information that may be required;
(ii) Understand you require this personal information, which will be retained by New India Assurance, so that you can evaluate my / our claim;
(iii) Authorized you to obtain details of claims made by me / us under policies with other insurers and personal information about me / us that is in your view potentially relevant to this claim;
(iv) Understand that I / we have certain rights of access to and correction of the personal information held by you.

This information is required under the terms of your policy. Failure to provide it may result in your claim being declined.