Aviva Broker: Liability claims form - Third Party Property Damage

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Liability claims instruction form - Third Party Property Damage

Please fill out the below form with as much information as possible. Mandatory fields are highlighted with an asterisks.

Name of insured*

Business name*

Policy number*

Is the schedule attached? (for scheme policies)* (optional)

Contact at insured to deal with investigations

Name*

Contact telephone number*

Email address*

Happy for us to contact the insured directly?

Broker contact

Name*

Contact telephone number*

Email address*

Reference (optional)

Incident information

Date of incident *

Please enter the date in the format dd/mm/yyyy

Incident circumstances*

Claimant details

Name*

Contact telephone number*

Email address*

Reference*

Details of damage

What is being clamed for*

Reporting as information only

Any other information

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Liability claims instruction form - Third Party Property Damage

Liability claims instruction form - Third Party Property Damage

Please fill out the below form with as much information as possible. Mandatory fields are highlighted with an asterisks.

Contact at insured to deal with investigations

Broker contact

Incident information

Claimant details

Details of damage

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