Accident/Incident Notification Form

Please fill out the below form to start the process of reporting your accident/incident process. A member of our claims team will be in touch shorty to go through your information.

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Policyholder Name *

Policy Number *

Date of Loss *

Policyholder Contact Number *

Policyholder Email Address

Policyholder Postal Address *

Include if differs from Risk Address

Policyholder Communication Preference

Tell us who would like to be kept informed of the claim, and how (phone/Email)

Details of Any Representative Appointed by the Policyholder

If a solicitor or Public Loss assessor has been appointed please provide details here, including contact details

Broker Email Address: *

Note: A copy of the form will be sent to this address.

Broker Contact Number *

Notification Type *

Property/ Liability/Motor claim

Incident Details *

Incident Location *

Please include Eircode, if aware.

Third Party Name (If Third Party Involved)

Third Party Contact details

Please record here if the Third Party is known to the Policyholder

e.g. Employee of Policyholder

Submit