Liability claims instruction form

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Liability claims instruction form

Please fill out the below form with as much information as possible. All fields are mandatory unless stated as optional.

Name of insured

Business name

Policy number

Please send the schedule (for schemes policies) to glasnew@aviva.com along with your other attachments.

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 location/full address

Please provide the full address and post code

Type of incident

Please provide applicable type

Employers Liability
Public Liability
Products Liability

Incident circumstances

Injury details

Injured party occupation

Time off work

Start date

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

Ongoing

End date (optional)

Please fill in if applicable but leave blank if still ongoing

Reporting as information only

Any other information

e.g. Letter of claim, Claim notification form (CNF), Accident book entry (if available)

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Liability claims instruction form

Liability claims instruction form

Contact at insured to deal with investigations

Broker contact

Incident information

Time off work

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