Fillable Form 1: Public Liability Claim Form (NIG)

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Form 1: Public Liability Claim Form (NIG)

On average this form takes 17 minutes to complete

The Form 1: Public Liability Claim Form (NIG) form is 3 pages long and contains:

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  • 68 other fields

Country of origin: UK
File type: PDF

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Name of the Insured
Address
Town County
Postcode Date Premium Paid
Business/Occupation Telephone Number
Policy Number Value Added Tax. Are you
a registered person or company? Yes No
You the Policyholder
1
a Date (dd/mm/yyyy) Time
am pm
b Exact place where Accident/Loss occurred
c Give full details of how the accident occurred
d Name and Address of the Person who caused the Accident
e Name and Address of his/her employers
f Describe the work you or your employees were engaged to do
g Total number of your men employed on the contract
i direct employees
ii sub-contractors under your direction whether or not labour only
h Name and Address of the Company/Person for whom you were
working and/or under contract
i Who were the Main Contractors?
Circumstances of the Claim
2
Public Liability Claim Form
NIG Commercial Claims P O Box 1151 Bromley BR1 9WB
Please note - you can complete this form on screen. When completing please use the tab and arrow keys to move between the relevant
fields. Ensure you do not use the return or enter keys.
If completing by hand, please answer all questions using BLOCK CAPITALS.
j Give the name of the person injured, or of the owner of the
damaged property
k Address
l Occupation
m Is this person in your service? Yes No
I
f no, state Name and Address of his/her Employers
C
ircumstances of the Claim
continued
2
Damage
a
D
escription of the property damaged
b Nature and extent of the damage
c Where can the damaged property be inspected?
Injury
d
Nature of the injury
e Date ceased work (dd/mm/yyyy)
f Date resumed (dd/mm/yyyy)
g Name of the hospital to which the injured person was taken
h Was the injured person detained?
i Give the name and address of all witnesses: (indicate if own
employee or independent)
j Have the police taken particulars? Yes No
If yes, state identity of Officer and Station to which he/she attached.
k
Have you received notice of the claim? Yes No
If yes, from whom, when and in what form?
If the claim is in writing please forward with this form
l
Have any steps been taken to compromise or settle the
matter in anyway?
Yes No
If yes, what and by whom?
m
Are there any other policies covering you for this accident?
Yes No
If yes, give details
General Information
3
n The following documents are requested:
Insured Claim Number Broker Reference
G
eneral Information
continued
3
S
tandard Document Disclosure List
A
vailable
Records of inspection for the relevant area
Maintenance records including reports of independent contractors working in relevant area
Records of the minutes of meetings where maintenance or repair policy has been discussed or decided
Records of complaints about the state of the area
Records of other accidents which have occurred on the relevant area
Copies of any contracts or other documents relating to sale or agreement
Copies of leases if accident involves premises
Document
I/We declare that no material information has been withheld and that all statements on this form are true to the best of my/our knowledge and belief.
In addition the articles and property belong to the persons named and no other person has any interest whether as Owner, Mortgagee or Trustee.
I/We understand that you may seek information from other insurers to check the answers I/we have provided, and I/we authorise the giving of such
information for such purposes.
Insurers and their agents share information with each other to prevent fraudulent claims and for underwriting purposes via the Claims and
Underwriting Exchange Register, operated by Insurance Database Services Ltd. A list of participants is available on request. The information
you supply on this form, together with the information you have supplied on your application form and other information relating to the claim,
will be provided to participants.
Signature Date (dd/mm/yyyy)
Please complete and return this form as soon as possible. Damaged property should be protected from further deterioration but not disposed of
without prior reference to the Company. If the claim is for repairable damage i.e. buildings, a Trademan’s estimate will be required.
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
NIG1102Q/06/15
NIG policies are underwritten by U K Insurance Limited, Registered office: The Wharf, Neville Street, Leeds LS1 4AZ.
Registered in England and Wales No 1179980. U K Insurance Limited is authorised by the Prudential Regulation Authority
and regulated by the Financial Conduct Authority and the Prudential Regulation Authority.
Calls may be recorded.
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Form 1: Public Liability Claim Form (NIG)

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Completed 27 March 2021

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