HomePublic Liability Claim - Genesis Insurance Brokers

1. Complete this form in detail and return it to the Company without delay.
2. The Hollard Insurance Company are commited to resolving valid claims within the shortest possible time; in order to assist in
expediting this process kindly ensure that this form is completed in detail.
3. A person making a claim against you must not be advised that you are insured or as to the terms and extent of your insurance.
4. All claims made against you must be advised to the Company immediately on receipt and all communications forwarded unanswered
to the Company.
5. The Company will, subject to the terms and conditions of the Policy, undertake your defence in any legal action and all notices or
advice of such action must be forwarded to the Company forthwith.
6. The issue of this form must not be considered as an admission of liability on the part of the Company, but is in accordance with the
terms and condition of the Policy
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Broker/Agent
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Policy Number
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Insured

Name of Company
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Is the company insured as a VAT vendor
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Company VAT/Reg No.
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Occupation
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Address/Business Address
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Telephone No. (Work)
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Cell Phone No.
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E-Mail
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Details of loss/damage

Date of Accident
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Time of Accident
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Place where accident occurred
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Detail and comprehensive statement setting out circumstances surrounding the loss
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Do you believe you were negligent, and if so, why?
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If Yes, Why?
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What measures were taken to prevent loss or damage?
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Third Party

Name of person injured or owner of property damaged
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Age of injured Person
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Business or occupation
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Is the letter from the third party attached
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If not, please request.
Has the third party appointed attorneys
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Please provide details of the attorneys or any correspondence received
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Please give full details of

i) Details of injury or loss
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Telephone no. (Work)
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Cell phone no.
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E-Mail
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Provide as much detail as possible (Attach drawings/maps/statements, etc.)

ii) Damage to property of Third Parties
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iii) If damage caused to motor vehicle, please complete:

Manufacturer
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Year model
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Model
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Vehicle registration number
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Location of damages on vehicle
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Witness

Please give name and address of any witness(es). (If none were obtained, please state whether any were available and reason for not providing particulars.)
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Relationship to insured
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Contact details
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Police

Police station and reference number
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Date reported
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Other Insurances

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If so, give particulars
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Property Owners

(To be completed only if claim is under Property Owners’ Policy)
Name and address of your tenant
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Property Owners

(To be completed only if claim is under Property Owners’ Policy)
Upload your documents...
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Declaration

I/We warrant that the answers given are true and correct. All details provided on this form are done so honestly and in good faith. This means that The Hollard Insurance Company Ltd have been made aware of all important information and that any incorrect information may mean that the claim may be rejected and the policy cancelled.
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Insured’s signature
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Insured’s full name
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Capacity
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Date
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Port Elizabeth
49 Worraker Street, Newton Park, Port Elizabeth, 6001
Johannesburg
41 Waterford Office Park, Waterford Drive, Fourways, 2055
Cape Town
5 Frere Avenue, Flamingovlei, Cape Town, 7441
Port Elizabeth
49 Worraker Street, Newton Park, Port Elizabeth, 6001

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