Incident notification form

If you are unsure if the incident that has occurred requires a claim, fill the form below and one of our team will evaluate it, and decide if it requires a new claim to be raised.
If you need to raise a claim please follow the New Claim path.

Section 1 - Reporter details (You as the reporter)

 

Are you a Dentist?
Are you a member of:
Are you a Pharmacist?

Please lodge your professional indemnity related claims/incidents via Pharmaceutical Defence Limited (PDL) by logging into the PDL Incident Reporting System (www.pdl.org.au) or by contacting them on 1300 854 838.

This process relates to PDL members who take out their membership directly with PDL as well as Guild Insurance Business Insurance policyholders with Professional Liabilities cover who have automatic PDL membership.

As part of your membership, PDL's Professional Officers who are pharmacists, provide you with risk management advice for incident management and regulatory notifications.

If your claim/notification relates to another type of liability incident (e.g. public or products liability) or any other type of claim that you have cover for then you can provide notifications directly to Guild Insurance by closing this window and selecting the Go back button to take you to the What best describes the nature of your claim? and select the appropriate option.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADANSW

If you are a member of the Australian Dental Association in NSW (ADANSW), please contact your association directly to report an incident or claim.

ADA NSW Advisory Services - (02) 8436 9944

 

 

 

 

 

 

 

 

 

ADASA

If you are a member of the Australian Dental Association in SA (ADASA), please contact your association directly to report an incident or claim.

ADA South Australia - (08) 8272 8111

 

 

 

 

 

 

 

 

 

 

ADATAS

If you are a member of the Australian Dental Association Tasmania (ADATAS), please contact your association directly to report an incident or claim.

ADA Tasmania - (03) 8825 4600

 

 

 

 

 

 

 

 

 

 

ADAVB

If you are a member of the Australian Dental Association in VIC (ADAVB), please contact your association directly to report an incident or claim.

ADA Victoria Branch Dispute Assistance - (03) 8825 4600

 

 

 

 

 

 

 

 

 

 

 

 

IMPORTANT

If you are a member of Australian Dental Association (ADA), please contact your association directly to report an incident or claim.

 

 

 

 

 

 

 

Are you reporting on behalf of someone else?*
Is this a notification only, or do you require a call to back to discuss further?

Section 2 - Policy information

 

Section 3 - Event details

 

Was a person involved?*
Was there anyone else involved?*

Section 3.5 - The event

Section 4 - Post event details

Has communication been received from a regulatory or disciplinary body?*
Add another
Has a demand been received for compensation, either verbally or in writing (including legal proceedings)?*
Add another
Have you admitted responsibility?*

Why do you believe this? Is anyone else responsible? Please provide these details.

Add another

Section 5 - Insurance information

Are there any other insurance policies which may provide cover in respect of this incident?*

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?

Complete the code below before submitting