Claim Form Please fully complete, upload any correspondence and click the submit button. Please enable Javascript in your Browser in order to correctly submit this form.1: InsuredGST Registered *YesNo2.Claimant or Other Party3.Claimant’s Solicitor or Representative4: 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 copy8.: 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 interestUpload attachmentPlease upload documents in PDF format only.DeclarationI/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 answersSubmit