Professional Indemnity

Professional Indemnity Claim Form

Insured Details

Period of Insurance

From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Are you registered for GST purposes?

Claimant / Potential Claimant

Insured's Retainer / Contract

Max. file size: 512 MB.

Claim or Circumstance

When did you first become aware of the Claim or the fact or circumstance that might give rise to a Claim?
MM slash DD slash YYYY
When was the Claim or an intimation of a Claim first made against you?
MM slash DD slash YYYY
Was the Claim or an intimation of a Claim made in writing?
Was the Claim or intimation of a Claim made verbally?

Your Comments

Declaration

Important: The information and answers given above are a true and complete statement of the facts and matters relating to the happening for which this claim is made, and no information likely to affect this claim has been withheld. I authorise my Insurer to undertake on my behalf whatever actions are necessary to indemnify me within the terms of my policy including if necessary, removal of my vehicle to alternative premises to enable repairs to be carried out by a qualified Motor Body Repairer. I understand that this claim may be refused if information is untrue, inaccurate or concealed. I expressly agree that the information given by me is provided with my full knowledge and consent and further agree to hold harmless and indemnify [Value not set] in the event of any action or matter that may be taken by any party pursuant to the Privacy Act 1988 (Cth). I/We acknowledge that I/we have read and understood the paragraphs accompanying this proposal headed ?Your Privacy?
Agree
Date
MM slash DD slash YYYY

Confused? Don’t worry, that’s what we’re here for.
Call us on 1800 958 384

Our contact details:

Phone: +61 2 9959 2900
Fax: +61 2 9959 2999
Email: [email protected]

Our contact details:

Phone: +61 2 9959 2900
Fax: +61 2 9959 2999
Email: [email protected]