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Public Liability Accident Report Form
Instructions
To enable Insurers to fulfil its obligations under the terms of the policy this form must be completed and submitted to the appropriate Area Claims Office together with all relevant accident documentation e.g. letter of claim, internal investigation report, etc. Details of any serious accident should be notified immediately irrespective of whether a claim has been made.

In the event of a fatal accident the Company should be notified immediately by telephone or facsimile in order that representation at the enquiry into the death can be arranged.

No payment, offer or promise of payment or admission of liability in any way should be made. No inspection of plant or machinery should be allowed unless agreed by Iron Trades Insurance.

Any communication received about the accident should not be answered but sent to Iron Trades Insurance Immediately.

Policy Number *
Name of Insured: *
Address
Post Code Telephone No:
Contact Name Telephone No:
Name of Third Party
Address
Post Code Date of Birth:
Occupation National Insurance No:
Date of Accident Time of Accident
Place of Accident
Circumstances of accident/disease
Was the accident/disease caused by any other party? If yes, please provide details:
YesNo
Details of property damage or injury sustained:
Estimated Cost of Repairs
Details of any plant or equipment involved:
Was the equipment Hired
YesNo
If yes was the hire subject to CPA Agreement
YesNo
Was the work been undertaken the subject of any contract?
YesNo
Did you manufacture the product.
YesNo
Please enclose explanatory literature or brochure concerning products
Name of Foreman/Supervisor
Name and Address of Witness
Email Address - *
This email address will be used for correspondence regarding this On-Line form and for no other purpose.
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