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Submit A Claim

PUBLIC LIABILITY CLAIM FORM

"*" indicates required fields

Step 1 of 7

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1. Complete this form in detail and return it to the Company without delay.

2. The Company is committed to resolving valid claims within the shortest possible time; in order to assist in expediting this process kindly ensure that this form is completed in detail.

3. A person making a claim against you must not be advised that you are insured or as to the terms and extent of your insurance.

4. All claims made against you must be advised to the Company immediately on receipt and all communications forwarded unanswered to the Company.

5. The Company will, subject to the terms and conditions of the Policy, undertake your defence in any legal action and all notices or advice of such action must be forwarded to the Company forthwith.

6. The issue of this form must not be considered as an admission of liability on the part of the Company, but is in accordance with the  terms and condition of the Policy

Insured

Is the company insured as a VAT vendor*

Details of loss/damage

DD slash MM slash YYYY
Do you believe you were negligent*

Third Party

Is the letter from the third party attached*
If not, please request.
Has the third party appointed attorneys*

Please give full details of

Drop files here or
Max. file size: 64 MB.

    iii) If damage caused to motor vehicle, please complete:

    Witness

    Police

    DD slash MM slash YYYY

    Other Insurances

    Have you any other insurance in force in respect of this occurrence*

    Property Owners

    (To be completed only if claim is under Property Owners’ Policy)
    Drop files here or
    Max. file size: 12 MB.
      (To be completed whenever applicable)
      Attach drawings/maps/statements, etc.
      Declaration*
      I/We warrant that the answers given are true and correct. All details provided on this form are done so honestly and in good faith.
      This means that The Insurer has been made aware of all important information and that any incorrect information may mean that the claim may be rejected and the policy cancelled.
      Insured’s signature
      Insured’s full name
      Capacity
      DD slash MM slash YYYY
      Date
      To submit this form, you need to accept our Privacy Statement*
      Privacy Statement
      This field is for validation purposes and should be left unchanged.

      Johannesburg Office:

      +27 11 789 7845
      41 Waterford Office Park, Waterford Drive, Fourways, 2055
      • +27 11 789 7845
      • 41 Waterford Office Park, Waterford Drive, Fourways, 2055

      Cape Town
      Office:

      Cape Town Office:

      +27 21 556 8371
      5 Frere Ave, Table View, Cape Town, 7441
      • +27 21 556 8371
      • 5 Frere Ave, Table View, Cape Town, 7441

      Port Elizabeth Office:

      +27 87 701 2222
      49 Worraker Street, Newton Park, Port Elizabeth, 6001
      • +27 87 701 2222
      • 49 Worraker Street, Newton Park, Port Elizabeth, 6001
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      Big Enough To Make A Difference

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      Small Enough To Care,
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      Genesis Insurance Brokers (Pty) Limited is an Authorised Financial Services Provider. Licence number 14995.

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