RMCC Liability Incident Report Form

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RMCC Liability Incident Report Form Powered By Docstoc
					Roads and Traffic Authority – NSW



                             Road Maintenance Council Contract
                                    RTA - Principal Arranged Insurance

                                   LIABILITY INCIDENT REPORT



All incidents (regardless of excess) likely to lead to claims should be reported,
irrespective of the amount.

Do NOT admit liability.

Any claim, writ, summons, process or any other documents relating to this
incident should be immediately given to the RTA Project Manger or RTA
Insurance Manager for forwarding on to Aon Corporate Risk Services
Australia Limited.

RTA Insurance Team:

Location:        Level 12, 101 Miller Street                      Postal Address:
                 North Sydney NSW 2059                            Locked Bag 928
                                                                  North Sydney NSW 2059

Attention:

Goran Bogdanoski
Insurance Co-ordinator
Telephone: (02) 8588 5275
Fax:       (02) 8588 4124                      Email: goran_bogdanoski@rta.nsw.gov.au

Judith Harris
Insurance Manager
Telephone: (02) 8588 5277
Fax:        (02) 8588 4124                     Email: judith_harriss@rta.nsw.gov.au




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Roads and Traffic Authority – NSW



          RTA – Principal Arranged Insurance – Liability Claim Form
General
Site Location: ……………………………………………………………………………………………………………..
Project Manger: …………………………………………………………………………………………………………..
Contractor making claim: …………………………………………………………………………………………………
Phone: ………………………… Fax: ……………………………. Email: ……………………………………............
Incident Details
Date of Loss: …… / …… / ……..                                 Time (approx.): …………………………………………..

Adverse Weather (please specify) ………………………………………………………………………………………..

Description of alleged incident. Please provide details of the factual circumstances only. Do not include comments
regarding fault or liability.

……………………………………………………………………………………………………………………………..

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Details of Incident as Alleged by Third Party
Personal Injury                         Property Damage                      Other
……………………………………………………………………………………………………………………………..

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Third Party Details
Name: …………………………………………………………………………………………………………………….
Address: …………………………………………………………………………………………………………………..
Phone: ………………………… Fax: ……………………………. Email: ……………………………………............
Witness Details (if any)
Witness 1
Name: …………………………………………………………………………………………………………………….
Address: ………………………………………………………………………………………………………………….
Phone: ………………………… Fax: ……………………………. Email: ……………………………………............
Witness 2
Name: …………………………………………………………………………………………………………………….
Address: ………………………………………………………………………………………………………………….
Phone: ………………………… Fax: ……………………………. Email: ……………………………………............
Name of Person completing form: ……………………………………………… Position: ……………………………………..
Email: …………………………………………………………………………………………………………………………………..
Company: ………………………………………………………………………………………………………………………………
Address: ……………………………………………………………………………………………………………………………….
Signature: …………………………………………………………………                               Date: ………. / ………… / ………


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posted:11/24/2011
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