Professional & Financial Liability

IMPORTANT INFORMATION

Use this notification form to notify claims on all liability policies except General, Employers’ and Statutory Liability policies. For these claims, please use the Liability Claim form.

You should not make any admission of liability, make any offer of settlement or incur any defence costs without your insurer's prior approval.

Policy Details

Specify policy

Policy Number

Name of insured

First

Last

Phone

Contact name

First

Last

Address

Address Line 1

City

State

Zip Code

Claim details

Who is or may be bringing a liability claim against you?

First Name

Last Name

Address

Address Line 1

City

State

Zip Code

Have they made a written or verbal claim against you?

Yes

Type of claim

Verbal

Written

If Yes, on what date did you receive it?

On what date did you become aware of the circumstances which you are notifying?

On what date or between what dates did you carry out the activities which gave rise to the claim or circumstance which you are notifying?

Please provide full details of claim being made against you or the circumstances that you consider may give rise to a claim.

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Please provide details of your relationship with the claimant including any work you have carried out for them to which the claim relates

How much is being claimed from you?

How much do you estimate the claimant’s loss to be?

Do you consider that you are at fault and why?

Have you made any admissions of liability or responsibility?

Yes

If Yes, please provide details

Have you obtained any legal or other advice about the claim against you?

Yes

If Yes, please provide details.

Other Information

Do you have any other insurance policies which may cover this claim?

Yes

Are you attaching any supporting or relevant documents?

Yes

What risk management steps have you taken / are you planning to take to prevent similar circumstances arising again?

If Yes, please list them

Declaration

(a) I am authorised to complete this form on behalf of the Insured.

(b) The information given above is correct and complete to the best of my knowledge and belief.

(d) I authorise the use of this information (and any further information supplied by me or the insured during the course of the claim) by Clarity Insurance Broker to administer this claim.

(e) I authorise the disclosure of this information by Clarity Insurance Broker to its advisers, reinsurers and other insurers.

(f) I understand that I / the insured have certain rights of access to and correction of this information.

Signature of Principal, Partner or Director

Sign Here

Date

Claims

Professional & Financial Liability

Policy Details

Claim details

Other Information

Declaration

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