Liability claim form.

For Public, Personal and other Legal Liability claims. Submit within 30 days. Fields marked * are required.

1. Policy & Contact Information

Policy Number *

Broker / Agent

Your Name *

Contact Number *

Email Address *

2. Incident Details

Date & Place of Incident *

Description of Incident *

3. Other Party & Damage

Other Party Name & Contact

Type of Damage / Injury

Property Damage Personal Injury Other

Nature of Damage / Injury — details

Police Report Filed?

Yes No

Station & Ref #

4. Claim Type

This claim is *

A claim by another party against me A claim by me against another party

5. Declaration & Consent

I declare that the information provided above is true, complete, and accurate to the best of my knowledge. I consent to Hollard collecting and processing my personal data to assess and process this claim in accordance with the Data Protection Act. I understand my data may be shared with third parties involved in processing this claim (assessors, repairers, reinsurers, etc.).

You can read Hollard’s full Data Privacy Statement at hollard.co.bw/…/hollard-privacy.

Submitting sends your claim to INERCA. We act for you, so we review it and lodge it with Hollard — you don’t need to contact Hollard yourself.

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INERCA Refined Insurance Solutions · licensed insurance agent, NBFIRA 2/10/686. We act for you with Hollard and Westlife; the insurer decides the claim.

Stuck? Call +267 78 607 912 or message us on WhatsApp.