Lumley Liability Claim Form

Lumley Liability Claim Form

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  liability claim form Wesfarmers General Insurance Limited, ABN 24 000 036 279 Claims Procedure This claim form is to be completed if you have been involved in an incident or accident that may give rise to demands being made against you. It may be necessary for you to make arrangements to prevent further accidents or incidents from occurring. It is necessary for you to complete all Sections of this claim form and attach all relevant documentation. Please answer all parts of the appropriate questions relevant to the incident or accident. If there is insufficient space provided for any information requested or to be supplied, please supply these details on a separate sheet and attach to the claim form. On receipt of the above we will assess and administer your claim in accordance with your policy. We will also keep you informed of any other requirements should they be required and we will keep you advised on the progress on the processing of your claim. If you have any queries on any of the information required on this form, please do not hesitate to contact your authorised representative or broker or Lumley Insurance office. Privacy We respect your privacy and we comply with the Privacy Act and the National Privacy Principles. A copy of our Privacy Statement is available at any of our offices or online at www.lumley.com.au Complaints Procedure If you do not agree with any decision we make in relation to the policy, please write to us stating what you disagree with and why. We will then resolve or attempt to resolve your complaint immediately, or we will refer the matter to our Internal Dispute Resolution Committee (IDRC). If you are not satisfied with a decision by the IDRC, the matter may be referred to an independent dispute resolution body, Financial Ombudsman Service (FOS), provided the matter falls within their jurisdiction. Financial Ombudsman Service (FOS) Freecall 1300 78 08 08 Post: GPO BOX 3, Melbourne Victoria 3001 Website: www.fos.org.au Email: [email protected] The Insurance Contracts Act 1984 (as amended) requires you to provide all information which Lumley Insurance may reasonably require, and stipulates that any omission may adversely affect the cover under your policy. If you would like more information on your duty of disclosure (or any other aspect), please contact your authorised representative, broker or nearest Lumley Insurance office. NSW Lumley House, Level 9, 309 Kent Street, Sydney 2000 Phone (02) 9248 1111 Fax (02) 9248 1122 Suite 19, 50 Glebe Road, The Junction 2291 Phone (02) 4925 7500 Fax (02) 4940 0295 VIC Level 3, 99 King Street, Melbourne 3000 Phone (03) 8627 4333 Fax (03) 8627 4312 ACT Level 4, 10 Rudd Street, Canberra City 2601 Phone (02) 6279 0333 Fax (02) 6279 0330 TAS Level 1, 27 Paterson Street, Launceston 7250 Phone (03) 6345 4700 Fax (03) 6345 4711 SA 465 Pulteney Street, Adelaide 5000 Phone (08) 8228 1700 Fax (08) 8228 1775 WA Level 9, 50 St George’s Terrace, Perth 6000 Phone (08) 9220 8222 Fax (08) 9220 8251 QLD Level 2, 99 Melbourne Street, South Brisbane 4101 Phone (07) 3307 4800 Fax (07) 3307 4899 LGI327 (07/09) Level 5, Northtown Tower, Flinders Mall, Townsville 4810 Phone (07) 4722 6000 Fax (07) 4724 4398 NT Level 2, Beagle House, 38 Mitchell Street, Darwin 0800 Phone (08) 8946 4600 Fax (08) 8228 1775 Lumley Insurance is a trading name of Wesfarmers General Insurance Limited 1.
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  Click on thefields to complete online, then print and sign. OR Print and complete all sections in black or blue pen. 1. Policy Details Policy number Claim number Expiry date (dd/mm/yyyy) Sum insured $ 2. Client Details Name of Insured Address Suburb State Postcode Phone number (w) Phone number (h) Email Goods and Services Tax - to ensure you do not incur any unnecessary GST liabilities on this claim please advise your: (a) ABN, if applicable (b) entitlement to an Input Tax Credit in respect of: (i) Insurance premium % and (ii) the property which is the subject of this claim % 3. Details of Accident Where did the accident happen? Date of accident (dd/mm/yyyy) Time am pm State clearly how the accident occured. Yes No Have you received any indication that a demand or claim will be made upon you for the incident or accident? If Yes, please provide details (include details of who is making the demand upon You and attach all documentation that You have received if the demand or claim has been made in writing). Yes No Was the accident reported to the Police or Workcover? If Yes, please provide details of who attended. LGI327 (07/09) 2.
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  4. Witness Name Age Address Name Age Address 5. If damage caused to property Name Address Description of property Nature of damage Estimate cost of damage $ 6. Injury to persons Name Age Nature of injury Name Age Nature of injury Yes No Do you know of any other insurance policy which covers the damage of items/injuries under our policy? If Yes, please explain 7. Declaration I/We solemnly and sincerely declare: 1. That the information supplied on this claim form and statement of claim is true in every respect 2. I/We understand that the claim may be refused if information is withheld, false, misleading or concealed 3. That there was no other insurance covering this loss current at the date of this incident 4. I/We acknowledge that this claim form is a legal document and as such may be used in any legal proceedings resulting from this claim. Signature of insured(s) Date (dd/mm/yyyy) Witness Date (dd/mm/yyyy) LGI327 (07/09) 3.