Public/Products Liability Incident Claim

(If applicable, please complete the following)

The Privacy Act 1988 requires us to tell you that your insurer will collect your personal and sensitive information in order to calculate your loss and entitlements, determine their liability, compile data and handle claims. When handling claims, they may have to disclose your personal and other information to third parties such as other insurers, reinsurers, loss adjusters, external claims data collectors, investigators and agents or other parties as required by law.

You have the rights to seek access to your personal information and to correct it at any time.

Disputes are not an everyday occurrence with any insurers. However all insurers provide an internal dispute resolution process should any dispute arise. Please feel free to ask for details.

If you are not satisfied with the outcome of this process, your insurer will advise you how to contact their external independent complaints scheme. (subject to eligibility).

I / We certify that the information given in this form is truthful, accurate and complete. No Information likely to affect this claim has been withheld. I / We understand that this claim may be refused if information is untrue, inaccurate or concealed.

I / We acknowledge that I / we have read and understood the Privacy Act 1988 information referred to above and consent to the collection, storage, use and disclosure of personal and sensitive information of all persons affected by this claim, with their approval. I / We acknowledge that if I / we do not agree to the collection of this personal and sensitive information then your insurer will be unable to process my / our claim.