Professional Indemnity Claim Form

Important

Please read the claim form fully prior to answering the questions.

The claim form is to be completed and signed by a partner, director or principal of the insured.

All questions must be answered as fully as possible.

Please use additional sheets if necessary and copies of relevant documentation should be attached.

If you have any questions in relation to completion of the claim form, please contact us:
01270 252 252 / claims@johnheath.com

Name of Business	«Contact_FullName»
Status	«Contact_CompanyType»
Trading name (if applicable)	«Contact_TradingName»
Company Number	«Contact_CompanyRegNo»
Address	«Contact_ContactPerson_AddrFullComma»
Business Established Date	«Contact_YearEstablished»
Contact Name	«Contact_ContactPerson_FullName»
Email	«Contact_ContactPerson_Email»

Details of Claimant

Full name of the claimant or potential claimant (i.e. the party making the claim or potential claim against you or the firm/company)
Address of the claimant

Details of Your Contract

What were you contracted to do? Please provide as much detail as possible
Was the contract evidenced in writing? If Yes, please attach a copy with this form
When did you perform the work from which the claim arises?
Who is the person within your business that actually performed the work or against whom the claim is principally directed?
What is that person’s title/duties and contract details?
Please provide full details of any other parties involved in the project – eg sub-contractors or main contractor details

Details of claim or circumstance

What is the precise nature of the claim (i.e. the claimants allegations) or the fact or circumstance that might give rise to a claim? Please provide as much detail as possible.
Have legal proceedings commenced? If yes, please attach a copy of all court documents
On what date did you first become aware of the claim or of the fact or circumstance?
On what date was the claim/circumstance first made to you?
Was the first indication of the claim verbally or in writing? If in writing, please attach copies, if verbal please describe the conversation (“I said”, “He said”)
What amount is claimed?
How is that amount calculated?

Detail of Your response

What are your comments in response to the claim or circumstance?
What are your comments regarding the value of the claim?
What is your estimate of your potential monetary liability to the claimant?
Are there additional details about which you wish to advise, or which may be of interest to an insurer, so that insurer will have a better understanding of this matter? If so, please provide details along with supporting documentation.
Have you instructed a Lawyer/Solicitor? If yes, please provide their details

IMPORTANT

To ensure that your claim is not prejudiced please note the following:

Do not respond to any correspondence or communication without prior approval of your Insurer.

Do not make any admission of liability to the claimant or their representatives

Do not make the claimant or their representatives aware of your Insurers involvement in this matter.

DECLARATION

I/We declare that the statements and particulars in this claim form are true and that I/We have not mis-stated or suppressed any material facts. I/We undertake to inform insurers of any material alteration to these facts.

Signed:	Date: