Public Liability Claim
The issue of this form is NOT an admission of liability on the part of the Company. Please answer all questions fully and return form without delay to
ALLIANZ NIGERIA INSURANCE PLC
Name of Insured
*
Policy No
*
Address
Contact person
Telephone Number
*
Occupation or Business
2
Contact Details
Name of Insured
*
Position
Telephone Number
*
E-Mail:
*
Address
Describe the precise contract work undertaken at the time of the incident
3
Liability
Do you feel you are liable for the accident
please select
Yes
No
If not, please confirm who is liable and why
4
Third Party/Claimant
Name
Address
Mobile Phone No
5
Injury
What injuries was sustained
Where was third party treated
Was there third party retained in the hospital
6
Property Damaged
Please describe the property damaged
Who owns the property
Has any claim be made on behalf of the third party either verbally or in writing
please select
Yes
No
Was the claim written or verbal
please select
Yes
No
Declaration
I/We
Position of the insured and on behalf and on behalf of the insured declared above answers to be true and correct AND acknowledge that the insurer may make its decision on indemnity having regard to these answer
Signature
Date
Submit
Send Filled Content
Receivers' Email