General Liability Claims Form
Collect your online responses with Jotform and turn them into professional, elegant PDFs automatically.
Unfortunately the unexpected does happen!
This form collects personal information about you so that the insurer can evaluate your claim. Failure to provide this information may result in your claim being declined. The collection of this information is required as part of the terms of your insurance policy. It will be held by, your Appointed Brokerage and the insurer who received your claim. You have the rights of access to and correction of this information subject to the provisions of the Privacy Act 2020. Please visit our website to view our full Privacy Statement.
I/We declare that to the best of my knowledge the details provided in this claim form are true. I/We have not withheld any information likely to affect the insurers consideration of the claim.
I/We agree to the appointed insurance brokerage and the Insurance Company (and/or their agent) with whom I am insured may disclose my/our personal information regarding this claim to:
Other parties including other members of the Insurance Industry and the data base of the Insurance Claims Register (ICR Ltd) PO Box 474, Wellington where it will be retained and made available to other insurance companies to inspect.
Parties who have a financial interest in the subject matter of the policy and parties repairing or replacing the subject matter of the claim.
I/We understand that I am/we are entitled to have certain rights of access to and correction of the personal information held by the appointed adviser and the Insurer and ICR Ltd.
I/We agree to the appointed insurance brokerage and the Insurer obtaining personal information about me/us that is, in their view, relevant to this claim.
From any other party including other members of the Insurance Industry and from Insurance Claims Register Ltd (ICR) which holds details of claims made by me/us under policies with other insurers.
All information and answers (whether written or oral) given to the appointed adviser and the Insurance Company in connection with this claim are correct and that no information relevant to the claim has been omitted. I/We authorise the appointed brokerage and the Insurance Company to act on my/our behalf.
The Certificate of Insurance PDF Template provides for use comprehensive details what is usually contained in an Insurance Policy. This certificate of Insurance Template contains information on types and limits of coverage, policy number, the policy holder's name, the named beneficiaries, insurance company, the policies' effective periods, and other important details to the policy.
This Certificate of Liability Insurance PDF Template provides comprehensive information as proof of coverage for the named insured for the certificate producer's or issuer's use. It has extensive details about an insurance policy.
Create an insurance waiver for employees declining insurance coverage. Works great on any device. Easy to customize and share. No coding knowledge required.
Automatically generate custom insurance quotes with this free, online Insurance Quote Template! Download or print as PDFs. Share with clients in seconds.
Job Safety Inspection Report is another type of audit template to check whether a company is compatible with important safety measurements. This reports sample features critical fields on the safety of employees.
Create a professional insurance agreement. Accessible from any smartphone, tablet, or desktop. Drag and drop to customize. Share and embed quickly.
These templates are suggested forms only. If you're using a form as a contract, or to gather personal (or personal health) info, or for some other purpose with legal implications, we recommend that you do your homework to ensure you are complying with applicable laws and that you consult an attorney before relying on any particular form.