Form name:
<div class="rounderCornerMiddle"> <div id="wrapper"> <div class="headerText"> LIABILITY CLAIM FORM </div> <div> <strong> 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. <br /><br />This form must be completed by a person authorized to do so on behalf of the Policyholder/ Insured. <br /><br />All questions must be answered as fully as possible (use additional pages if necessary) </strong> </div> <fieldset> <legend>Policyholder(s) / Insured Details</legend> <div class="itemField"> <div class="listDiv2"> Full Name: </div> <div class="listDiv"> <input type="text" name="txbFullName" /></div> </div> <div class="itemField"> <div class="listDiv2"> Address: </div> <div class="listDiv"> <textarea rows="5" cols="22" name="txbAddress"></textarea></div> </div> <div class="itemField"> <div class="listDiv2"> Contact Details: </div> <div class="listDiv"> <input type="text" name="txbContactDetails" /></div> </div> <div class="itemField"> <span class="blueBolderText">Telephone: </span> </div> <div class="itemField"> <div class="listDiv2"> Work: </div> <div class="listDiv"> <input type="text" name="txbWork" /></div> </div> <div class="itemField"> <div class="listDiv2"> Home: </div> <div class="listDiv"> <input type="text" name="txbHome" /></div> </div> <div class="itemField"> <div class="listDiv2"> Mobile: </div> <div class="listDiv"> <input type="text" name="txbMobile" /></div> </div> <div class="itemField"> <div class="listDiv2"> E mail: </div> <div class="listDiv"> <input type="text" name="txbEmail" /></div> </div> </fieldset> <fieldset> <legend>Policy Details </legend> <div class="checkboxItemField"> <label>Policy Type</label> <input type="radio" value="Public Liability" name="rbtnPolicyType" /> <input type="radio" value="Employers Liability" name="rbtnPolicyType" /> <input type="radio" value="Statutory Liability" name="rbtnPolicyType" /> <input type="radio" value="Carriers Liability" name="rbtnPolicyType" /> </div> <div class="itemField"> <div class="listDiv2"> Policy Number : </div> <div class="listDiv"> <input type="text" name="txbPolacyNumber" /></div> </div> <div class="itemField"> <div class="listDiv2"> Limit of Indemnity: $</div> <div class="listDiv"> <input type="text" name="txbIdentityLimit" /></div> </div> <div class="itemField"> <div class="listDiv2"> Excess: $</div> <div class="listDiv"> <input type="text" name="txbExcess" /></div> </div> </fieldset> <fieldset> <legend>Third Party Details </legend> <div class="itemField"> <div class="listDiv2"> Claimant Name: </div> <div class="listDiv"> <input type="text" name="txbClaimant" /></div> </div> <div class="checkboxItemField"> <label>Does the Claimant have a direct or indirect financial interest in you?</label> <input type="radio" value="Yes" name="rbtnFinancialInterest" /> <input type="radio" value="No" name="rbtnFinancialInterest" /> </div> <div class="checkboxItemField"> <label>Is the Claimant related to you in any other way?</label> <input type="radio" value="Yes" name="rbtnRelatedOtherWay" /> <input type="radio" value="No" name="rbtnRelatedOtherWay" /> </div> <div class="itemField"> <div class="listDiv2"> If yes, to either of the above question, please explain.</div> <div class="listDiv"> <textarea rows="5" cols="35" name="txbAnswer"></textarea></div> </div> </fieldset> <fieldset> <legend>Relevant Dates</legend> <div class="itemField"> <div class="listDiv2"> Date accident/possible error occurred giving rise to complaint, claim or possible claim. </div> <div class="listDiv"> <input type="text" name="txbPossibleError" /></div> </div> <div class="itemField"> <div class="listDiv2"> Date complaint, claim or intimation of claim first made</div> <div class="listDiv"> <input type="text" name="txbDateComplaint" /></div> </div> <div class="itemField"> <div class="listDiv2"> Date Insured first became aware of complaint, claim or possible claim</div> <div class="listDiv"> <input type="text" name="txbDateInsured" /></div> </div> <div class="checkboxItemField"> <label>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? </label> <input type="radio" value="Yes" name="rbtnExistanceOfComplaint" /> <input type="radio" value="No" name="rbtnExistanceOfComplaint" /> </div> </fieldset> <fieldset> <legend>Past Losses and Current Claims</legend> <div class="itemField"> Please list below all losses or circumstances (whether or not resulting in claims) paid or outstanding during the past five years: <table width="500" cellspacing="2" cellpadding="0" border="1"> <tbody> <tr class="blueBolderText"> <th> Year of Loss </th> <th> Description of Loss </th> <th> Amount Paid </th> <th> Amount Outstanding </th> </tr> <tr> <td> <input type="text" name="txbYearOfLoss1" /> </td> <td> <input type="text" name="txbDescriptionOfLoss1" /> </td> <td> $ <input type="text" name="txbAmountPaid1" /> </td> <td> $ <input type="text" name="txbAmountOutstanding1" /> </td> </tr> <tr> <td> <input type="text" name="txbYearOfLoss2" /> </td> <td> <input type="text" name="txbDescriptionOfLoss2" /> </td> <td> $ <input type="text" name="txbAmountPaid2" /> </td> <td> $ <input type="text" name="txbAmountOutstanding2" /> </td> </tr> <tr> <td> <input type="text" name="txbYearOfLoss3" /> </td> <td> <input type="text" name="txbDescriptionOfLoss3" /> </td> <td> $ <input type="text" name="txbAmountPaid3" /> </td> <td> $ <input type="text" name="txbAmountOutstanding3" /> </td> </tr> <tr> <td> <input type="text" name="txbYearOfLoss4" /> </td> <td> <input type="text" name="txbDescriptionOfLoss4" /> </td> <td> $ <input type="text" name="txbAmountPaid4" /> </td> <td> $ <input type="text" name="txbAmountOutstanding4" /> </td> </tr> <tr> <td> <input type="text" name="txbYearOfLoss5" /> </td> <td> <input type="text" name="txbDescriptionOfLoss5" /> </td> <td> $ <input type="text" name="txbAmountPaid5" /> </td> <td> $ <input type="text" name="txbAmountOutstanding5" /> </td> </tr> <tr> <td> <input type="text" name="txbYearOfLoss6" /> </td> <td> <input type="text" name="txbDescriptionOfLoss6" /> </td> <td> $ <input type="text" name="txbAmountPaid6" /> </td> <td> $ <input type="text" name="txbAmountOutstanding6" /> </td> </tr> </tbody> </table> </div> </fieldset> <fieldset> <legend>Nature Of Claim Or Circumstance</legend> <div class="itemField"> 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.</div> <div class="itemField"> <textarea rows="7" cols="65" name="txbBackgroundEvents"></textarea> </div> <div class="itemField"><span class="blueBolderText">Quantum at issue</span></div> <div class="itemField"> <div class="listDiv2"> Amount of claim or estimate of claimant’s alleged loss:$</div> <div class="listDiv"> <input type="text" name="txbAmount" /></div> </div> </fieldset> <fieldset> <legend>Your Privacy </legend> <div class="itemField"> We collect and receive your personal information in this claim form to consider your claim. We Act 1993. <br /><br />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. <br /><br />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.</div> </fieldset> <fieldset> <legend>Your Declaration</legend> <div class="itemField"> 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. <br /> <br /> I / We<br /> (i) Agree to give any further information that may be required; <br /> (ii) Understand you require this personal information, which will be retained by New India Assurance, so that you can evaluate my / our claim; <br /> (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; <br /> (iv) Understand that I / we have certain rights of access to and correction of the personal information held by you. <br /><br /> This information is required under the terms of your policy. Failure to provide it may result in your claim being declined. </div> </fieldset> </div> </div>