Public Liability Report Form

Public Liability Claim Form - Property Damage

Policy or Claim Number

SECTION 1 - INSURED'S DETAILS

Policy holder name
Address
Number and street
Town/City
Postcode
Telephone
email
Contact name
Business/Occupation
VAT registered	Yes No

SECTION 2 - THE ACCIDENT

Date and time of accident
Address at which damage occurred
Number and street
Town/City
Postcode
State exactly how the damage occurred

SECTION 3 - PROPERTY DETAILS

Name and address of third party
Number and street
Town/City
Postcode
Was the accident caused by any other party?	Yes No
If yes, please provide details
Details of property damage sustained
Estimated cost of repairs
Details of any plant or equipment involved
Was the equipment hired?	Yes No
If yes, was the hire subject to CPA agreement?
Was the work being undertaken the subject of any contract?	Yes No
If yes, please give details

SECTION 4 - WITNESSES

Please give names and addresses of all witnesses

SECTION 5 - DECLARATION

I declare that the above statements are true and correct to the best of my/our knowledge and belief. I have not withheld from the insurer any information within my knowledge connected with this claim.

I agree to provide the insurers with any further information and documentation as may be reasonably required. I understand that insurers do not admit liability by the issue of this form.

I agree
Position
Date

If you would prefer to complete your form on paper, please download the PDF file below.

Public Liability Report Form

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