Turner and Company - Claims - Commercial Claims

Your Details

The Event (if applicable)

Date
Time	: am pm
Location
When was it first notified to you
By whom?

State fully what happened

What precautions against the accident/injury had previously been taken?

What plant or equipment, if any, was involved?
Has any authority investigated the event?	Yes No
Details

If an employee caused the event, state name, address & occupation

If the event arose out of work under contract, has any indemnity or disclaimer been given or received?

Name & Addresses of all witnesses (if written statements obtained, please attach)

Name of Person in charge at the time
Do you have any other Insurances which may cover this claim?
Yes No

Attachment

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Declaration

I declare that the above statements are true and correct to the best of my knowledge and belief

I have not withheld any information within my knowledge connected with this form

I agree to provide the Insurer with any further information or documentation as may be reasonably required

I understand that the Insurer does not admit liability by the issue of this form

I confirm I am authorised to provide information contained in this form

I confirm that I have read and understand the above declaration. *

Full Name: *		On behalf of: (if applicable)
Date:	11/10/2008	Position:
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Name
Date of Birth
Address
Occupation
Injuries Sustained
Name of Doctor / Hospital where treated