BBi Berns Brett Claims Reporting Services

Liability Claims Reporting Services
If you need to make a claim fill in the form below,
email us here or contact us by telephone on 0800 3588 222.

SECTION 1 - Insured

Title
Full Name
Number & Street
Area/Town
City/County
Postcode
Telephone Number
Mobile Phone
Fax Number
Email Address
Berns Brett Client No.
Policy No.
Your Insurance Company

SECTION 2 - Accident

Date
Time
Exact location of the accident
Who notified you of the accident.
When was the accident notified
State fully what happened
Has Notice of Accident or Dangerous Occurance form been completed : (If Yes, please send a copy by post.)
What plant or equipment, if any, caused the accident : Any relevant plant or equipment must be kept in a safe place.
Names and addresses of all witnesses. If written statements obtained, please forward by post :
If particulars were taken by a police officer, give details eg. number, station etc :

SECTION 3 - Employee

Complete this section if the injury / disease is to your employee
Title
Full Name
Number & Street
Area/Town
City/County
Postcode
Berns Brett Client No.
National Insurance No.
Date of Birth
Occupation
Are they married
Are they a direct employee to you
Average weekly earnings inclusive (net of tax) £
Total earnings paid to date
Statutory sick pay
Total sick pay paid to date
Maximum entitlement period (weeks)
If applicable, details of other payments made during incapacity
State full details of injuries / disease sustained
If applicable, date and time employee ceased work
Has he returned to work
Name and place of hospital to which employee taken

SECTION 4 - Employee

Complete Part A if property is damaged, and/or Part B if a person (not your employee) is injured.
PART A
Details of damage
Name and address of owner(s)
PART B
Details of injury/disease
Name and address of owner(s)
Name and address of injured person(s)
Name and place of any hospital to which injured person taken
If known, state name of employer

SECTION 5 - Claim

Has any claim been made upon you
If Yes, give particulars
Any communication that you receive about the incident from other parties should NOT be answered but sent to Berns Brett immediately.

SECTION 6 - Further Inquiries

Name
Business Address
Number & Street
Area/Town
City/County
Postcode
Please tick the box to agree that the information supplied in this form is accurate to the best of your knowledge/belief.
All information supplied is used by Berns Brett Ltd for underwriting purposes.