Get Allianz ALL 82.qxd

Include information relative to any other loss or damage not covered by questions 1 2 or 3 of this form. Policyholder s Signature Date Allianz 3 Cromac Quay The Gasworks Ormeau Road Belfast BT7 2JD Tel 028 9089 5600 Fax 028 9043 4222 E-mail info allianz-ni. Transit Claim Form 1 Insured Name of Policyholder Address Postcode Policy No* BT CGL Phone No* Home Business Email Do you use conditions of trading If Yes What are they Work Yes Are they applicable in this case If No do you accept common law liability If No what liability do you accept under contract or agreement with the customer concerned What is the upper limit of such liability No Please attach copies of Consignment Notes Bills of lading and other documents and/or correspondence evidencing the terms agreed with your customer and any other parties involved in the performance of the contract. 2 If Road Haulage or Freight Forwarding Contracts is Involved A Consignor s Name and Address B Collection Point if different from above Name and Address C Consignees name and address D If Traffic was sub-contracted to you please state Principal contractor E If your vehicle was involved Make Registration No* Drivers name and address How long employed Years How many vehicles do you operate F Nature of Load No of items in load Weight of load Value of load Kgs G Date on which goods were i Collected ii Delivered H Signature given at collection Name Was signature i Clear If claused state remarks ii Claused J Date of first complaint other than traffic note Nature of loss or damage and description of load or part load damaged or pilfered K If carriage charges were raised on a capacity/volume basis please give details and submit copy of freight invoice 3 General Information A Has this matter been reported to the police or some other authority If Yes please give name and address of authority concerned Date reported Time Reference B Did the owner insure the goods Details of Insurers if known Not known Policy No* C If claim relates to damage where goods may be inspected Phone No* Gross amount of claim Value of salvage if any Net amount of claim Please supply a full description of the occurrence with employees statements attached if possible. In any case of an unexplained deficiency kindly give your views on probable explanation eg. misconduct faulty documentation etc* and indicate what steps have been taken to trace or locate the missing goods. co. uk Web Site www. allianzni. co. uk Allianz p*l*c* is authorised by the Central Bank of Ireland. Registered in Ireland No* 143108. Calls may be recorded or monitored for regulatory training and quality purposes. Transit Claim Form 1 Insured Name of Policyholder Address Postcode Policy No* BT CGL Phone No* Home Business Email Do you use conditions of trading If Yes What are they Work Yes Are they applicable in this case If No do you accept common law liability If No what liability do you accept under contract or agreement with the customer concerned What is the upper limit of such liability No Please attach copies of Consignment Notes Bills of lading and other documents and/or correspondence evidencing the terms agreed with your customer and any other parties involved in the performance of the contract. 2 If Road Haulage or Freight Forwarding Contracts is Involved A Consignor s Name and Address B Collection Point if different from above Name and Address C Consignees name and address D If Traffic was sub-contracted to you please state Principal contractor E If your vehicle was involved Make Registration No* Drivers name and address How long employed Years How many vehicles do you operate F Nature of Load No of items in load Weight of load Value of load Kgs G Date on which goods were i Collected ii Delivered H Signature given at collection Name Was signature i Clear If claused state remarks ii Claused J Date of first complaint other than traffic note Nature of loss or damage and description of load or part load damaged or pilfered K If carriage charges were raised on a capacity/volume basis please give details and submit copy of freight invoice 3 General Information A Has this matter been reported to the police or some other authority If Yes please give name and address of authority concerned Date reported Time Reference B Did the owner insure the goods Details of Insurers if known Not known Policy No* C If claim relates to damage where goods may be inspected Phone No* Gross amount of claim Value of salvage if any Net amount of claim Please supply a full description of the occurrence with employees statements attached if possible.