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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 +353 (0) 49 4331038

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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: