Bryte Public Liabilty – Report Form 1Insurer / Insured2Description of accident3Witnesses4Police5Property damage6Personal injuries7Declaration InsurerInsurerPolicy numberClaim numberBroker/AgentInsuredNameAddress and telephone numberBusiness or occupationEmail Please enter your email if you would like a copy. Description of accidentDate and timePlace where accident occurredState exactly how the accident occurred WitnessesWitnesses 1 - Name, address and telephone numberWitnesses 2 - Name, address and telephone number PoliceIf reported to police, state which station and reference numberPolice stationReference number Property damageName and address of ownerDescription of damage Personal injuriesName, address and age of injured person 1Details of injuryName, address and age of injured person 2Details of injuryIf persons named above is/are in your service, or your tenant, or related to you, give full detailsIf claim made against you, give details and attach any correspondenceAttach here Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB. DeclarationI/We declare that to the best of my/our knowledge the above statements are trueInsured’s signatureCapacityDate DD slash MM slash YYYY Protection of Personal Information Act (POPIA)All personal information collected on this form will be processed in accordance with our privacy statement. https://www.brytesa.com/pdf/Bryte_privacy_statement.pdfSigned atDayMonthYearSignature of policyholder
