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PUBLIC LIABILITY CLAIM FORM
The insured
Details of incident
Time
Other person(s) involved in this incident
Was someone injured
If yes please provide name and address of injured personal(s):

Repeater

Was any property damaged
If yes, please state name, address and phone no. of owner(s)

Repeater

Is the person making the claim against you:
An employee of the insured
An employee of a subcontractor
A member of insured's family
Ordinarily resident in the insured's home
Have you been notified on a claim against you ?
Verbally
In Writting

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If someone was injured ?
Give name(s), address(es) and phone number(s) of all witness(es):

Repeater