Claims Form - Lion Underwriting

Insured Details
Name of Insured
Contact Name
Policy Number*
Phone*
Email*
Broker Details
Brokerage Name
Contact Name
Email*
Phone*
Web Address
Incident Details
Date of loss/event:
Time & Date
Location
Damage Incurred/description of incident
Were there witnesses to the loss?*
- Yes
- No
Witness Name
Witness Phone Number
Were police advised
- Yes
- No
If Yes, please provide the incident report number
Any additional infomation
Insured Bank Details
Account Name
Bank Name
Account Number
Bank Name
Declaration
By signing this form you consent Lion Underwriting Pty Ltd using the information we may hold about you for the purpose of providing assistance in relation to handling claims, and to process sensitive personal data about you where this is necessary (for example criminal convictions). This may mean we have to give some details to third parties involved in providing insurance cover. These third parties may include insurance carriers, third-party claims adjusters, fraud detection and prevention services, reinsurance companies and regulatory authorities. In the course of performing our obligation to you, this information may be disclosed to agents and service providers appointed by us, Insurers, (including their re-insurers, legal advisers, loss adjustors or agents). Where such sensitive personal information relates to anyone other than you, you must obtain the explicit consent of the person to whom the information relates both to the disclosure of such information to us and its use by us as set out above. The information provided will be treated in confidence and, where relevant, in compliance with the Data Protection Act 1998. You have the right to apply for a copy of your information (for which we may charge a small fee) and to have any inaccuracies corrected.
Print name*
Signature*
On behalf of*
Date
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Insured Details

Broker Details

Incident Details

Insured Bank Details

Declaration

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