Allianz Sri Lanka | Notify Liability Claim

LIABILITY CLAIM NOTIFICATION

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1. INSURED DETAILS

Name of the Policy Holder

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Policy No

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Telephone No

Home / Office

Mobile

Email Address

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Date & Time of Loss

Date

DD/MM/YYYY

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Time am / pm

Nature or cause of loss

Address or Location where the event occurred

2. PERSONAL INJURY

If above is yes - Name and address of the Injured / Deceased

3. PROPERTY DAMAGE

If above is yes - please give name and address of the owners of the property.

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DECLARATION

The claim will be formally registered once written intimation is received by the company
List of documents & forms will be provided considering policy status is in-force on the date of event
Allianz Insurance Lanka Ltd reserves the right to ask for more documents and information’s to consider the claim
Claim proceeds are payable as per terms and conditions in the policy document
Notifications of claim, submission of claim forms and/or claim documents to the Company shall not be construed as admission of liability by the company
By submitting this form, you accept above terms and conditions.

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Notify Liability Claim

LIABILITY CLAIM NOTIFICATION

1. INSURED DETAILS

Telephone No

Date & Time of Loss

2. PERSONAL INJURY

3. PROPERTY DAMAGE

DECLARATION

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