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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