Liability – Claim Submission – Edge Underwriting

You must answer all questions honestly and fully. The completion of this claim form is not an admission of liability by your Insurer.

Please complete all sections below and press "Submit to ProClaim".

A record of the answers will be automatically emailed to you, your broker, and ourselves.

YOUR / INSURED'S DETAILS

Policy Number *0 / 10

Full Legal Name of Insured (Business/Company) *This is the policy holder. eg. ABC Pty Ltd

Trading Name of Insured (Business/Company) *

Street Address *

City *

State / Territory *

Post Code *

Insured's Contact Person *

Mobile Phone Number *Mobile preferred. If Landline, please include area code

Email Address *

DETAILS OF YOUR BROKER

Insurance Broker Company *

Contract Person (Broker) *

Mobile Phone Number (Broker) *Mobile preferred. If Landline, please include area code

Email Address (Broker) *

Would you prefer for ProClaim to deal direct with your broker? *

YesNo

DETAILS OF THE PARTY CLAIMING AGAINST YOU

Name of Business / Company / Individual *

Contact Person *

Mobile Phone Number *Mobile preferred. If Landline, please include area code

Email Address *

DETAILS OF THE ALLEDGED PERSONAL INJURY / PROPERTY DAMAGE

On what date did the alleged incident occur? *

On what date was it first reported to you? *

Please describe the alleged accident or incident in as much detail as possible. *

Who was allegedly involved *

You / The Insured / Your EmployeeYour Contractor / SubcontractorNot Applicable

Name of Employee *

Name of Company Contracted / Subcontracted *

Street Address *

City *

State / Territory *

Post Code *

Individual Involved *

Contact Person at their company *

Contact Persons Email Address *

Contact Persons Mobile Phone Number *Mobile preferred. If Landline, please include area code

Please upload a copy of the contract / agreement between you and your contractor / subcontractor

No file chosen

Please upload a copy ofyour contractor / subcontractor's liability policy that was I Force at the time of the alleged incident

No file chosen

Have you or any of your employees, contractors or subcontractors admitted responsibility in any way? *

YesNo

As you have answered "Yes", please provide full details *

ALLEGED VALUE OF CLAIM

Has anyone suggested how much they will be claimig from you? *

YesNo

Please advise alleged amount being claimed *

WITNESSES

Were there any witnesses? *

YesNo

Witness 1 Name *

Relationship to the Insured *0 / 200

Mobile Phone Number *Mobile preferred. If Landline, please include area code

Email Address *

Street Address *

City *

State / Territory *

Post Code *

Witness 2 Name

Relationship to the Insured0 / 200

Mobile Phone NumberMobile preferred. If Landline, please include area code

Email Address

Street Address

City

State / Territory

Post Code

Witness 3 Name

Relationship to the Insured0 / 200

Mobile Phone NumberMobile preferred. If Landline, please include area code

Email Address

Street Address

City

State / Territory

Post Code *

AT THE SCENE

Did any Emergency Services or other Authorities (eg. Work Safe) attend? *

YesNo

Report Number (if known) *0 / 20

Was it suggested that any charges or other action may be taken? *

YesNo

Please provide full details *

ANY OTHER INFORMATION / UPLOADS

Please feel free to provide any additional information you feel is relevant *

Please feel free to upload any additional relevant documents / correspondence you have received

Upload 3

No file chosen

Upload 4

No file chosen

Upload 5

No file chosen

Upload 6

No file chosen

DECLARATION

I, the under-named, hereby declare that: *

If any personal information is provided, it is understood that this information will be collected, held, used and disclosed by Insurer(s) and their service providers in order to issue, administer and manage products and provide services, including claims investigation and administration, and for data analyticsAll answers and statements made in this claim form are true, correct and complete in every respectWhere any part(s) of this claim form has been completed by others, I have checked their answers and confirm they are true, correct and complete in every respectI am authorised to act for and on behalf of all persons who may be entitled to indemnity under our Legal Expenses PolicyAuthorisation is given to obtain, from any other party, information that is, in the Insurer(s) or its service providers view, relevant to this claim.

My Full name (the person completing this form) *

My Position / Title *

My Mobile Phone Number *Mobile preferred. If Landline, please include area code

My Email Address *