Claim Form - Webber Insurance Forms

Professional Indemnity Claim Form

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Phone

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Work Request ID

Name*

Business Name / Name of Insured

Policy Number

Phone Number*

Email*

Name of Claimant / Potential Claimant*

Describe specifically the work you did for the Claimant*

What is the precise nature of the claim (i.e. the claimant’s allegation) or the fact or circumstance that might give rise to a claim?*

What date/s did the specific incident occur?*

What date/s did you become aware that this matter could be a circumstance or a claim?*

Please attach any relevant documentation for this matter

Drop files here or

Max. file size: 32 MB.

Provide the full name/s of the person/s who did the work in question*

Are they*

An employee

A contractor

Other

If other, please provide further details*

What are your defences to this matter?*

What compensation is the Claimant seeking, if any?*

How do you assess the Claimant's loss, if any?

What date did the Claimant's loss occur?

This electronic signature will be treated the same as if signed personally.