1: Insured

GST Registered *

YesNo

2.Claimant or Other Party

3.Claimant’s Solicitor or Representative

4: What were you retained or contracted to do*

5.Date the Loss, Accident or Circumstance occurred*

Specify the time of the Loss, Accident or Circumstance *

6.On what date did you first become aware of the claim*

7: Was the first intimation of a claim verbal or in writing*

Verbal Writing

if in writing, please attach copy

8.: The person who actually performed the work against whom the claim is principally directed.*

9.Describe the events surrounding the actual claim and what you are alleged to have done wrong *

10: What amount is being claimed or the estimated cost of the loss*

11. Are there any additional details you wish to advise or which may be of interest

Upload attachment

Please upload documents in PDF format only.

Declaration

I/We hereby declare that: The above answers to be true and correct and acknowledge that Insurer may make its decision on indemnity having regard to these answers