Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Miramar Public Liability Claim Form

278 views

Published on

Miramar Public Liability Claim Form

Published in: Business
  • If u need a hand in making your writing assignments - visit ⇒ www.WritePaper.info ⇐ for more detailed information.
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Did you try ⇒ www.HelpWriting.net ⇐?. They know how to do an amazing essay, research papers or dissertations.
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Hi there! I just wanted to share a list of sites that helped me a lot during my studies: .................................................................................................................................... www.EssayWrite.best - Write an essay .................................................................................................................................... www.LitReview.xyz - Summary of books .................................................................................................................................... www.Coursework.best - Online coursework .................................................................................................................................... www.Dissertations.me - proquest dissertations .................................................................................................................................... www.ReMovie.club - Movies reviews .................................................................................................................................... www.WebSlides.vip - Best powerpoint presentations .................................................................................................................................... www.WritePaper.info - Write a research paper .................................................................................................................................... www.EddyHelp.com - Homework help online .................................................................................................................................... www.MyResumeHelp.net - Professional resume writing service .................................................................................................................................. www.HelpWriting.net - Help with writing any papers ......................................................................................................................................... Save so as not to lose
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Be the first to like this

Miramar Public Liability Claim Form

  1. 1. 1MIRAMAR UNDERWRITING AGENCY PTY LTD  |  LIABILITY CLAIM FORM AFSL 314176  ABN 97 111 534 797 BUSINESS DETAILS If company, partnership etc, state full registered name or trading name first name last name company name (eg. abc company pty ltd) Address number, street address city / suburb state postcode Contact Numbers telephone number (day) telephone number (night) mobile fax insured policy number Liability Claim Form PART 1 – PLEASE COMPLETE FOR ALL CLAIMS SITUATION DETAILS LEASE/RENTED PREMISES In accordance with the Lease/ Rental Agreement, is the Landlord required to pay for the repairs or replacement?   Yes    No LOCATION Location at which loss, damage or accident occurred (e.g. address) For what purposes are the premises at the location occupied? DATE AND TIME Date which loss, damage or accident occurred? date from (dd/mm/yy) date to (dd/mm/yy) time (from) time (to) DAMAGE INCURRED What was the nature of the loss, damage or accident? (eg damage to roof tiles) How was it caused? (e.g. storm) What steps were taken to prevent or reduce further loss, damage or injury? Has any other person, other than you, an interest in the property?   Yes    No If Yes, please provide further details mir-p-lcf-813.1
  2. 2. 2Miramar Underwriting Agency Pty Ltd  |  Liability claim form AFSL 314176  ABN 97 111 534 797 Situation details (continueD) DAMAGE INCURRED Have you had any other insurance covering the property on liability?   Yes    No If yes, state the company and the amount insured company $ amount insured Was immediate notice given to Miramar of the loss?   Yes    No Have you, or anyone comprising the insured, either alone or with others, ever previously suffered a loss and/or claimed for a similar event?   Yes    No Has an invoice or account been paid?   Yes    No LEGAL LIABILITY Give, in full, particulars of any personal injury to or damage to property of any person Give name and address of person who suffered injury or property damage first name last name number, street address city / suburb state postcode Is the claimant legally represented?   Yes    No If yes please provide details Product Liability Were products manufactured by the insured?   Yes    No Directly imported by the Insurer?   Yes    No Name of person in charge at time of accident? full name If, in your opinion, anyone was to blame for the accident, state name and address and give reasons for your opinion full name address Reason for your opinion Give name and addresses of any witnesses full name witness ➊ address full name witness ➋ address full name witness ➌ address PART 2 – LEGAL LIABILITY
  3. 3. 3MIRAMAR UNDERWRITING AGENCY PTY LTD  |  LIABILITY CLAIM FORM AFSL 314176  ABN 97 111 534 797 LEGAL LIABILITY (CONTINUED) Has any claim been made upon you verbally or otherwise?   Yes    No If yes, give particulars and forward any correspondence to Miramar Underwriting Agency Was any liability admitted?   Yes    No Has any enquiry been held by the Police relative to the accident?   Yes    No If yes, state when and where IMPORTANT INFORMATION PRIVACY POLICY Contact details for Miramar Underwriting Agency are: Miramar Underwriting Agency Pty Ltd Level 5, 97-99 Bathurst Street Sydney NSW 2000 Phone +61 2 9307 6600 Fax +61 2 9307 6699 We are committed to protecting your privacy. We use the personal information you provide to us in connection with your claim only for the purpose of assessing and managing the claim. We may need to provide that information to our underwriters and reinsurers (and theirrepresentatives) and those we appoint to assist us with the claim. We will not trade, rent or sell your information. If you do not provide us with complete information, we cannot properly assess your claim. You can check the personal information we hold about you at any time. If you provide us with personal information about anyone else, we rely on you to have told him or her that you will provide their information to us, to whom we may provide it, the purposes for which we will use it and that they can access it. If the information is sensitive, we rely on you to have obtained their consent on these matters. For more information about our Privacy Policy, ask us for a copy. IMPORTANT INFORMATION FOR COMPLETION OF CLAIM FORM You should retain a copy of all information supplied to the insurers Please return your fully completed claim form to:- Your Broker Please use a separate sheet of paper if you need more space to complete any question DECLARATION I/We declare that the above particulars are a true account of the loss, damage or injury sustained by me/ us and that the claim shown above does not include any profit or advantage of any kind. I/We further declare that all the conditions and warranties of the policy have been faithfully complied with and that no party insured has willfully caused the said loss, damage or injury or sought unjustly to benefit thereby. Candidate  ➊ name title  X signature date (dd/mm/yy) Candidate  ➋ name title  X signature date (dd/mm/yy)
  4. 4. 4MIRAMAR UNDERWRITING AGENCY PTY LTD  |  LIABILITY CLAIM FORM AFSL 314176  ABN 97 111 534 797 NOTES mir-p-lcf-813.1

×