Incident Report Form
 Please complete and submit the following form in the event an incident has happened that may lead to a claim under your Insurance Policy.
This form is suitable for use for Material Damage claims such as Fire, Storm, Rainwater, Fusion, Burglary, Theft and Liability for Personal Injury and/or Property Damage.
IMPORTANT:Do not use for Workers Compensation, Professional Indemnity or Motor Vehicle Incidences.
Please read our Privacy Policy
Submission of this form will allow us to commence a Claim file and advise your Insurer. Certain questions prompt you for the submission of additional documentaion and we suggest these can be emailed or faxed to our office if available.
Note: As this incident report may be subject to FREEDOM OF INFORMATION (FOI) and/or DISCOVERY for litigation purposes, please ensure that only factual information is included in this form. Location Map and Contact Information


Your Name
Address
Insured Name
Phone
E-Mail
Risk Location
Insurer
Policy Number
Type of Incident


Description of Incident (Details):



Where did the incident occur? (Location)



Date/Time of Incident:



When did you first become aware of the incident?


Estimated Cost of Incident (not including cost of injuries if any) -provide details.(add/delete text)



If injuries occurred, have you received verbal or written demands?

Were the Police Notified? (add/delete text)



Any witnesses to the incident? (add/delete text)



Was anybody responsible? (add/delete text)



 

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