Claims Form

CLAIM FORM GUIDE – This form should be completed if a claim has been made against you or if you are aware of a circumstance which may lead to a claim being made against you. The form asks you to provide details of the work that you undertook, details of any potential claimant and any allegations that may be made against you. To assist us in handling your claim promptly and efficiently please make sure you provide us with as much information as possible.

As part of the claims service we will assist you with correspondence with the Claimant and their representatives. It is therefore very important that we give prior approval before any correspondence is sent to the Claimant or any other third party.

YOUR DETAILS

1) Policy Number


2) Name of firm / company / partnership / individual


3) Contact Director / Partner / Individual and reference


4) Address


5) Telephone and Fax


6) Email


CLAIMANT DETAILS

7) Name of Claimant / potential Claimant


8) Address contact details of Claimant / potential Claimant


9) Name, address and reference of Claimant’s solicitors or representatives


10) Are there any other Parties involved in relation to this claim/circumstance?
YES	NO

If YES, please identify and give details of their role


CURRENT STATUS OF CIRCUMSTANCE / CLAIM

11) Please give full details below of the claim/circumstance and attach any relevant correspondence received.

(Please restrict your file size to approximately 30 pages of Word / PDF doc)
Attach Document Here


12) Has a written response been sent to the Claimant or their representative?
If YES please attach a copy, NO

If yes please provide a copy. If the response was verbal then please summarise any relevant discussion(s).

(Please restrict your file size to approximately 30 pages of Word / PDF doc)
Attach Document Here


If your proposed response has not yet been sent to the Claimant/potential Claimant, please attach a copy of your draft proposed response for approval. We can assist you with drafting the response if necessary.
(Please restrict your file size to approximately 30 pages of Word / PDF doc)
Attach Document Here

13) Is any urgent action required (e.g: to reduce/avoid losses, to adhere to any contractual deadlines or to deal with court proceedings)?
YES,	NO

If yes then please provide details in the box below


CLAIM / CIRCUMSTANCE DETAILS

14) To enable us to understand the background of the claim/circumstance please summarise your role/involvement with the Claimant and attach any documentation which is relevant to the project and/or allegations made.


(Please restrict your file size to approximately 30 pages of Word / PDF doc)
Attach Document Here

Attach Document Here

Attach Document Here


15) What are your views on the allegations made? Do you think you – or any third party - may be liable?


16) Please give your best current estimate of the value of the claim/potential claim.


OTHER INFORMATION

17) Date on which you became aware of a circumstance which may give rise to a claim.


18) Date on which claim was actually made or intimated against you.


19) Date of the alleged negligent act/omission (i.e. when did the alleged mistake/error or failure happen).


ANY OTHER ADDITIONAL DOCUMENTATION

20) Please provide copies any of the relevant documentation which will enable us to assess this claim/circumstance. (Please restrict your file size to approximately 30 pages of Word / PDF doc)
Attach Document Here

Attach Document Here

Attach Document Here


CONFIRMATION (this form should be signed by a Director / Partner or Principal)
21) Please tick box to confirm that this information is correct and complete to the best of your knowledge.

Print Name:

Date:

Claims Form

YOUR DETAILS

CLAIMANT DETAILS

CURRENT STATUS OF CIRCUMSTANCE / CLAIM

CLAIM / CIRCUMSTANCE DETAILS

OTHER INFORMATION

ANY OTHER ADDITIONAL DOCUMENTATION

CONFIRMATION (this form should be signed by a Director / Partner or Principal)

CONFIRMATION

(this form should be signed by a Director / Partner or Principal)