personal and public liability insurance

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1 personal and pblic liability insrance personal and pblic claim report Insrer CGU Insrance Limited ABN

2 CGU Insrance Limited ABN Please keep this page for yor information Abot Yor Claim We will contact yo as qickly as possible abot yor claim. If someone else involved in the accident contacts yo abot a claim, or for information, refer the person to yor local CGU Insrance office. If yo receive a writ or smmons, or anything else from a legal firm, please send it to s immediately. We need to handle everything related to yor claim. Please refer to yor policy booklet for more information abot how yor claim will be handled. If yo have any qestions abot yor claim, please contact yor local CGU Insrance office. The telephone nmbers are: Adelaide (08) Perth (08) Brisbane (07) Sydney (02) Lanceston (03) Ballarat (03) Melborne (03) Newcastle (02) How yo can resolve a dispte with s Or dispte resoltion system is free and works like this: 1. Please advise the staff at yor local CGU Insrance office (phone nmbers above) if yo are dissatisfied with: or decision on yor claim, or handling of yor claim, the services of or loss adjster or investigator. 2. The staff member will try to resolve the problem. 3. If nable to resolve it, the staff member will refer it to the spervisor or manager for attention. A decision concerning yor complaint will be made within 15 bsiness days of receipt. 4. If this fails to resolve yor problem, yo may reqest that the problem be referred to or internal dispte resoltion staff. They will investigate the dispte and try to reach a satisfactory otcome with yo, normally within 15 bsiness days of the date yo reqested a referral. 5. Brochres otlining or internal dispte resoltion process are available from yor nearest CGU Insrance office.

3 CGU Insrance Limited ABN Personal and Pblic Liability Claim Report Please answer all qestions. This will help s process yor claim qickly. If yo need more space to answer any of the qestions, please se a separate sheet of paper. Any attachments will form part of this claim report and the declaration will inclde them. 1. Policy nmber : : : : : : : : : : : Expiry date Yo can find the information for qestion 1 on yor policy or renewal schedle. 2. Insred (srname, company, partnership) Given name(s) of insred Contact person (for company or partnership claims) 3. Are yo registered for GST prposes? What is yor ABN? : : : : : : : : : : Have yo claimed or do yo intend to claim an inpt tax credit on the GST applicable to this policy? Is the amont claimed or intended to be claimed less than 100% of the GST applicable to the premim? Specify the percentage amont claimed or intended to be claimed % Private telephone no. Bsiness telephone no. Facsimile no. 6. Type of bsiness (for company or partnership claims) Accident details 7. When did the accident happen? Date Time a.m. p.m. 8. where the accident happened a) Do yo own the land or bildings where the accident happened? State name and address of the owner b) Do yo occpy the land or bildings where the accident happened? State name and address of the occpier

4 9. a) Describe what happened b) Who cased the injry or damage? c) What is their relationship to yo? d) Do yo consider yo are liable? Why? 10. a) Was the accident cased by a defect or hazard on the property where the accident happened? How long had yo been aware of it? b) Had anyone notified yo of the defect or hazard before the accident? When were yo notified? Who notified yo? What details were given? What steps had been taken before the accident to rectify the defect or hazard? 11. Did the accident involve: a) Plant or eqipment? Describe it Do yo own it? Who is the owner?

5 b) A motor vehicle? Type of vehicle Reg. or identification nmber Driver s name Driver s address Owner s name (if not the insred) Owner s address Private telephone no. Bsiness telephone no. c) Animals? Type of animal(s) Do yo own the animal(s)? If someone else is also responsible for the animal(s), please provide name and address Is the animal, or grop of animals, normally confined behind fences? Have there been similar incidents involving the animal(s)? 12. Who reported the accident to yo? When was it reported? Time a.m. p.m. 13. List any witnesses Witness no. 1 Fll name Telephone no. Witness no. 2 Fll name Telephone no.

6 14. Did the police attend the accident? Officer's name of station 15. Have yo received a claim from the injred person, or the owner of the damaged property? Attach any correspondence relating to this claim 16. What is yor relationship to the injred person, or the owner of the damaged property? 17. Is there any other insrance which might apply to this claim? Provide details and attach a copy of the contract(s) Injry details 18. a) and address of injred person b) Occpation Employer c) Age Male Female Private telephone no. Bsiness telephone no. 19. What were the injries? 20. Was medical assistance necessary? Doctor Amblance Hospital of Doctor/Hospital Property damage details 21. and address of the owner of the damaged property

7 22. Describe the property and the damage 23. Estimated cost of repair or replacement $ Declaration I declare that to the best of my knowledge and belief the information in this form is tre and correct and I have not withheld any relevant information. I consent to CGU Insrance sing my personal information I have provided on this form for the prpose of processing my claim. I nderstand that if I choose not to provide the reqired details, this is my choice, however, CGU Insrance may not be able to process my claim. * I consent to CGU Insrance disclosing my personal information to other insrers, an insrance reference service or as reqired by law. I consent to CGU Insrance also disclosing my personal information to and/or collecting additional information abot me, from investigators or legal advisers. Signatre of the insred or person with athority to sign for and on behalf of a company or partnership Date * This consent only applies when a claim is sbmitted in relation to a policy issed to the individal, not a company or bsiness. Please indicate the nmber of additional pages attached to this claim report When complete, please forward this claim report to: CGU Insrance, GPO Box 9902 in the capital city of yor state or or agent or yor broker or yor local CGU Insrance office

8 Insrer CGU Insrance Limited ABN HOC0014_pdate REV7 11/08

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