Professional indemnity claim form

If you wish to report an incident with regards to your professional indemnity insurance  please fill out the incident report form below.

Section 1 - Policy information

 

Will you be the main contact for this claim?*

Are you the Insured Policyholder?*

Do you give authorisation for anyone else to act on your behalf for this claim?*


Section 2 - Event details

 


Section 3 - Injury information

Was anybody injured?*


Section 4 - Property damage information

Was any property damaged?*


Section 5 - Further details

 

Please upload any relevant documents

This field is required

Add another

Section 6 - Information regarding GST

 

Are you registered for GST?*

Have you claimed an input tax credit for the GST included in your insurance policy premium?

If yes, was the amount of GST claimed less than 100% of the GST included in the premium?