NSURE Liability Claim Form Logo

  • LIABILITY CLAIM FORM

    If any questions, please contact us at 1300 067873

  • Note: This form must be completed by the policyholder NOT the injured party. To be completed when accident causes damage to property or injury to a member of the public.

  • YOUR PRIVACY

    The Privacy Act 1988 requires NSURE General Insurance Advisors to make the following disclosure before collecting personal information about you after 21 December 2001:

    ·                NSURE collects personal information in order to provide it’s various services which include insurance broking, claims management, risk management consultancy, underwriting management, and reinsurance. 

    ·                If the personal information NSURE requests from you is not provided, NSURE or any involved third party may not be able to provide the appropriate services.

    ·                NSURE discloses personal information to third parties who are involved in the provision of our services. For example, in arranging and managing your insurance needs NSURE may provide information (including sensitive information such as health information) to insurers, reinsurers, other insurance intermediaries, it’s advisors such as loss adjusters, lawyers and accountants, and other parties involved in the claims handling process.   By signing this form and continuing to deal with us, you confirm on your behalf and/or on behalf of those you represent consent to NSURE and these parties collecting, using and disclosing personal and sensitive information about you.

    ·                NSURE has a duty to maintain the confidentiality of it’s client’s affairs which includes their personal information. Our duty of confidentiality applies except where disclosure of your personal information is with your consent or required by law.

    ·                NSURE may make use of your personal information to provide you with information about it’s products and services.  

  • 1. Details of Policyholder

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  • 2. Details of Accident / Injury

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  • 3. ABN Details

  • 4. Declaration

  • I declare that the above statements are true, that I have not suppressed or mis-stated any facts.  I expressly agree that the information given by me is provided with my full knowledge and consent and further agree to hold harmless and indemnify NSURE General Insurance Advisers in the event of any action or matter that may be taken by any party pursuant to the Privacy Act 1988 (Cth).  I/We acknowledge that I/we have read and understood the paragraphs accompanying this proposal headed "Your Privacy".

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