General Liability Claim Form

  • 1. Insured Or Company Details





  • 2. Claim Details


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  • :



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  • 3. Third Party Details













  • 4. Property Damage Details













  • (if a vehicle is involved please include year, make, model and registration)




  • Yes, provide details













  • Declaration

    I declare that to the best of my knowledge and belief the information in this form is true and correct and I have not withheld any relevant information.
    I/we agree that, by submitting this form, the personal information I/we provide to PSC Connect Pty Ltd in this form or otherwise may by collected, held,
    used and disclosed in the manner set out in the PSC Privacy Policy found at http://www.pscconnect.com.au/privacy/ including for processing this claim


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