JUA Underwriting Agency Pty Limited

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JUA Online Claim Notification Form for Liability Insurance.
JUA prides itself on responsiveness and prompt settlements. Please submit this Form and a JUA consultant will respond to you within 2 working days.


	1. Insurance Broker

	Name of the Insurance Broking Firm:
	Address:

		Suburb: State: Postcode:
	Name of the Insurance Broker:
	Contact details:	Phone :
		Fax:
		Email:


	2. The insured

Policy Number:
Insured's Full Name:
Postal Address:

	Suburb: State: Postcode:
Contact Numbers:	Business :
	Private:
	Mobile:
Tax Status:	Registered business:	Yes No
	ABN:
	Taxable %:
Occupation:


	3. Third Party

	Name:
	Relationship to Insured:
	Postal Address:

		Suburb: State: Postcode:
	Contact Numbers:	Business:
		Private:
		Mobile:
	Age:	years


	4. Particulars of Accident/Incident

	Date:	Time:
	Date reported to you:	Time:
	Location:
	Describe how the accident/incident occurred:
	If you have admitted responsibility in any way give details:


	5. How Reported

Reported by:	Name:
	Address:

	Suburb: State: Postcode:
Contact Numbers:	Business:
	Private:
	Mobile:

	Name:
	Address:

	Suburb: State: Postcode:
Contact Numbers:	Business:
	Private:
	Mobile:
	How:	In Person By Phone By Letter Other
Reported to:	Name:
	Address:

	Suburb: State: Postcode:
Contact Numbers:	Business:
	Private:
	Mobile:
	Position:


	6. Cause

Was accident due to:	The actions of any individual/s	A Motor Vehicle
	Property	An Animal
	Plant or Equipment	Other - Please specify:
If other please specify full details here:
Please complete full details of appropriate section below:


	Actions of Individual/s:

	Please provide their name, address and relationship to you (ie. claimant, employee, member of your family, sub-contractor, etc.)
	Name Address Relationship


	Property:

	Do you own the property?	Yes No - If "No", state name and address of owner:

	Do you occupy the property?	Yes No - if "No", state name of tenants and the type of tenancy:

	Had any notice been given of any defect or hazard by your agent or tenants? Yes No
		If "Yes", date notified: By whom were you notified?
	What details were notified?

	What type of property caused the accident? (E.g. defect in the property or spillage of some substance, etc.)


	Plant or Equipment:

Describe plant or equipment and it's uses:


	Motor Vehicle:

	Type of Vehicle:
	Rego No.:
	Drivers Name:
	Address:

		Suburb: State: Postcode:
	Owners Name:
	Address:

		Suburb: State: Postcode:


	Animal:

	Type of Animal:
	How long have you owned the Animal?
	Is the Animal normally confined behind fences?	Yes No
	Has the Animal been involved in any similar incidents?	Yes No


	7. Treatment

	Was treatment given at the scene of the accident? Yes No
	If "Yes", by whom?
	Phone Number:
	Address:

		Suburb: State: Postcode:
	How severe was the injury in your opinion:
		Trivial Minor Major Serious
	Was transport provided?	Yes No
	Was Ambulance used?	Yes No


	8. Witness and their Relationship (i.e. employer, members of your family, etc.)

Name Address Relationship


	9. Police

	Did a Police Officer attend the accident/incident? Yes No - if "Yes", provide details:
		Name of Police Officer:
		Police Station:
	Did police lay any charges or intimate action may be taken? Yes No - if "Yes", provide details:

	Was transport provided?	Yes No
	Was Ambulance used?	Yes No


	10. Property Damage

	Description of property damaged:
	Nature and extent of damage:
	Has any demand for this damage been made against you? Yes No
	Please fax any demands to JUA.


	Privacy

	Amendments to the Privacy Act 1988 took effect on 21 December 2001. You can review our Privacy Policy on this website, accessible from the top right hand navigation menu. Please contact JUA for any further information.


	Declaration and Authorisation

	The information and answers given above are true and complete in every detail. I understand the claim may be refused, delayed or reduced if information is withheld. I authorise that JUA Underwriting Agency Pty Limited give to and obtain from other insurers, insurance reference bureaus and credit reporting agencies any information relating to the Insured's credit or insurance history as well as insurance claims information obtained during the course of this contract.
	Name
	Date
	How do you want to send this form to JUA? Please select an option:

			Print your Claim Notification details, sign it and fax to: (02) 9247 2411. Remember to also fax any necessary attachments.