DirtPak - Insurance for Heavy Machinery

Insured Name *

Company *

Phone *

Mobile *

Email *

Date of occurrence

Time

AM

FM

Exact place of occurrence

Suburb

State

Postcode

Name of person(s) injured or owner(s) of property lost or damaged

State nature of personal injury or loss/damage sustained

State exactly what happened and how it occurred

Witness(es) Name(s)

Address(es)

Has a report of personal injury/damage been made to you by a 3rd party claimant?

Yes

No

If so, when and by whom?

Have any claims been made on you either verbally or in writing?

Yes

No

Did you admit liability in any way?

Yes

No

Any estimate available for damaged property?

Yes

No

Have you any other information we should be aware of?

Your Name

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Liability Claims Report