Public Liability Claim Form

+242 774400-9

ABSOLUTELY NECESSARY THAT ALL THESE QUESTIONS BE FULLY ANSWERED

BRANCH(Required)

Untitled

POLICY NO(Required)

Name of Insured in full(Required)

OCCUPATION(Required)

ADDRESS(Required)

Place where the accident occurred(Required)

Date of Accident(Required)

MM slash DD slash YYYY

Time of Accident(Required)

Hours

:

Minutes

AM/PM

State in detail how the accident occurred(Required)

Give Name and Address of Person causing Accident and in whose employ?(Required)

Name and Address and Occupation of person injured or of Owner of property(Required)

Give details of nature and extent of injury or damage(Required)

Has any intimation of claim been made upon you?(Required)

Yes

No

When and what amount?(Required)

State to whom the accident was first reported(Required)

Date when the accident was first reported

MM slash DD slash YYYY

Names and Addresses of Witnesses to Accident ,if not taken ,give reason why(Required)

Was any evidence or Particular taken by any Policeman?(Required)

Yes

No

Give his number and station(Required)

Date(Required)

MM slash DD slash YYYY

A Member Of The Deposit Protection Scheme