Management Insurance Claim Form

"*" indicates required fields

Insured Name*

Email*

Phone Number*

Policy number*

Insurance Product*

Is this a Management Liability Claim?*

Yes

Is this a Employment Practices Claim?*

Yes

Claimant/Potential Claimant Details

Claimant Name*

Claimant Phone*

Claimant Address*

Claimants Solicitors (if any)*

Claim or Circumstance

Date of incident out of which a Claim has been or might be made against you.*

Date you first became aware that a set of circumstances existed, which may result in a Claim being made against you.*

Date you first received a notice of intention from party to make a Claim (If in writing, please provide a copy).*

Have you received a demand for compensation in writing? (If Yes, please provide a copy). If No, please provide details of allegations made against you.*

Insurance history

Have you had any claims in the last 5 years? (YES / NO If Yes, provide details.)*

Has any Insurance Company refused to renew or cancelled/terminated a policy? Has any Insurance Company refused a claim? (YES / NO If Yes, provide details.)*

Have you been convicted of or had any fines or penalties imposed for any criminal offences in the last 10 years? (YES / NO If Yes, provide details.)*

Additional information (optional)

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