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Personal Liability Claims Form

Policy Number
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SECTION 1: INSURED

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Name and Surname:
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Address
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Email Address
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Cell Number
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Work Number
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Home Number
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SECTION 2: INCIDENT

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Select a date
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Place of incident
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SECTION 3: WITNESS

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Name and Surname of witness
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Address
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Contact Number:
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SECTION 4: POLICE

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Police Station
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Police reference number
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Date
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SECTION 5: TYPE OF LOSS/DAMAGE

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Type of loss/damage
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SECTION 6: PERSONAL INJURIES (IF APPLICABLE)

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Name of injured person
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Address
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Age
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Relationship with the injured
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Details of injury
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SECTION 7: CLAIM

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Claim (if any claim has been or is being made against you, give details and attach any correspondence)
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Upload claim correspondence..
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SECTION 8: DESCRIPTION OF INCIDENT

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Describe exactly how the incident occured
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SECTION 9: DECLARATION

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I/ We hereby declare that to the best of my/our knowledge the above statements are true.

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Capacity
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Date
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