Public Liability Claim Form

(the company does not admit liability by the issuance of this form)
Fire and GA Claims Department : Fax: 6225 9887
Name of Policyholder
Policy No
Contact Person
Tel No
Email
NRIC No
Address
Are you GST Registered?
Please fill GST Registration No
Details of Accident
 
Date

Time
Place
State exactly how the accident happened
Who was to blame? Please provide reasons
If plant and/or machinery were used, please advise:
a) Name of person operating it at the material time of accident
b) Owner of the Plant and/or Machinery?
c) Name of Insurance Company of this Plant and/or machinery
If accident is attributed to defect in your premises or plant, please advise:
a) Nature of defect alleged :
b) Do you admit the defect alleged : 
c) Were you aware of the defect before accident :
d) What steps did you take to remedy it?
e) Have you order any alteration or repair after the accident?
f) Are all statutory obligations observed or complied with?
Details of negligent person
Name
Occupation
Address
How long has he/she been employed
Is he/she your employee?
Was he given any form of training
Please list witnesses' names if available:
Name
Address
Relationship to insured
Name
Address
Relationship to insured
Particulars of injured third party:
Name
Age
Occupation
Was the injured person contributory negligent?
Name of third party's employer
Does his contract include a provision indemnifying
you against accidents to his employees?
Address
Sex
Nature of injury
In what way was the injured contributory negligent?
Is third party's employer your sub contractor?
Does your contract include an indemnity to the Principal Contractor?
Particulars of third party's property damage:
Describe property damaged
Name of property owner
Has a claim been made upon you for this accident?
Nature of damage
Address of property owner
For what amount?
Declaration: I hereby declare and warrant that all the answers given above to be true. I accept that insurers would be at liberty to deny liability in part or in full if the above written answers are false or inaccurate in any aspect
Importance Notice:
1. The insured is required to furnish the Particulars above as fully and accurately as possible.
2. This form is sent without prejudice to the terms and conditions of the Policy and should not be regarded as a waiver by the Company of any breach of the Policy Conditions the Insured may have committed.
3. The acceptance of this form is not in itself an admission of liability on the part of the Company
4. If any person has been injured or damage caused to third party vehicle or property, DO NOT admit liability in any way.
5. Communication of any kind you received should be sent immediately and unanswered, to the Company.

Please note that all personal information provided to TMiS is subject to the Personal Data Protection Policy Statement posted at www.tokiomarine.com.sg under privacy statement.