Claim Notification

Claim Notification

• Insured Name:
• Phone No: *

Address

Street Address

City

State/Province/Region

Zip Code
• Policy No. : *
• Date you received first Notice of Claim:
• Was your first notice by:
  TelephoneReceipt of Suit PapersReceipt of Arbitration PapersReceipt of a LetterOther
• Please provide copies of all correspondence and the name, address and type of project involved in thi s claim:
• Please describe the services you rendered on this project and include the dat e(s) you rendered the services which resulted in the allegations:
• Does this claim involve a written contract?
  YesNo
• If so, please list the da te the contract was signed:
• If so, please provide a copy of this contract for our review. Does this claim involve a verbal contract or agreement ?
  YesNo

Claimant

• Name:

Address

Street Address

State/Province/Region

City

Zip Code
• Phone
• Has a suit been filed against you?
  YesNo
• Date served:
• Court in which suit filed:

Address

Street Address

City

State/Province/Region

Zip Code
• Number of days to answer:

Plaintiff 's Attorney

• Name:

Address

Street Address

City

State/Province/Region

Zip Code
• Phone No:
• Brief description of claim and alleged error or cause of claim:
• Was this claim or incident previously reported to another professional liability carrier?
  YesNo
• If so, please specify the carrier and the date notified.
• Please have principal, partner or officer sign this notification of cl aim.
• Signature
• Title
• Please attach to any other narrative or documentation that you feel will be helpful.

Section

 

Fieldset

 

Verification

• Please enter any two digits *Example: 12
• This box is for spam protection - <strong>please leave it blank</strong>: