Professional Indemnity Insurance Claim Form

Submit your
claim

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Insured Name*

Email*

Phone*

Policy number*

Insurance Product*

Claimant/Potential Claimant Details

Claimant Name*

Claimant Address*

Claimant Phone*

Claimants Solicitors (if any)*

Information Required

Who were you retained by / Who did you contract with?*

What were you retained/contracted to do? (if the retainer/contract was in writing, please provide a copy)*

When did you perform the work out of which the Claim has arising or may arise?*

Please provide the name of the person who performed the work*

Claim or Circumstance

What has been claimed against you or what fact or known circumstance might give rise to a claim?*

When did you first become aware of the Claim or the fact or circumstance that might give rise to a Claim?*

When was the Claim or an intimation of a Claim first made against you?*

Was the Claim or an intimation of a Claim made in writing (If Yes, please provide a copy)?*

Was the Claim or an intimation of a Claim made verbally? (If Yes, please provide a copy)*

What is the likely quantum of the Claim or potential Claim?*

Insurance history

Have you had any claims in the last 5 years? (YES / NO If Yes, provide details.)*

Has any Insurance Company refused to renew or cancelled/terminated a policy? Has any Insurance Company refused a claim? (YES / NO If Yes, provide details.)*

Have you been convicted of or had any fines or penalties imposed for any criminal offences in the last 10 years? (YES / NO If Yes, provide details.)*

Additional information (optional)

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