PI Claim Form

Introduction
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Submit

Introduction

Claims will be notiﬁed to insurers between 9am and 5pm from Monday to Friday, (excluding bank holidays). Some insurers stipulate that acceptance of any notiﬁcation must be acknowledged by their own claims department before conﬁrming indemnity.

If your policy expires outside of business hours and you have a claim to notify, SBJ Professional will not be responsible for any matters not accepted by insurers. If you have an urgent matter, please contact us by telephone to discuss the position in the ﬁrst instance. A copy of this notiﬁcation form will be emailed back to you once submitted and should be retained by you for your own records.

Additional information can be added to this notiﬁcation form by uploading ﬁles from your computer. Please ensure that any ﬁles added are in either a MS Word, TIFF or PDF format.

Click here to view our claim and claim circumstance guide.

Details of the insured

Practice name

Main office address

Postcode

Main office telephone number

Contact email address

Services Provided

Please advise the following

Name of client or (claimant)

Date services rendered to your client

Commenced

Completed

Terms & conditions of your engagement and nature of services rendered

Are there any fees invoiced for services rendered by you that remain unpaid?

No Yes

If 'Yes', do you intend to pursue these fees?

No Yes

Amount of gross fees outstanding? £

Were any specialised consultants used?

No Yes

If 'Yes', please give details and a note of their duties together with how and by whom they were appointed

Notification details

Please give a resume of the facts which have led to the current situation

Date you first became aware of circumstances which might give rise a claim against your or loss incurred by you

Has any intention to claim against you been expressed?

No Yes

If 'Yes', by whom and in what circumstances?

If 'No', please explain the reason for anticipating a claim and provide full particulars as to dates, acts and persons involved

What are your own views on liability?

If possible, please give your estimate of the amount for which you may be liable on the following basis:

Worst possible £

Likely outcome £

Attach additional information

Please attach all relevant correspondence and in particular any formal claim notifications, upload your file here.

Your Details

Your name

Your position

Declaration

By submitting this form, I declare that the above statements and particulars are true, full enquiry having been made, and I have not omitted, suppressed or mis-stated any material facts and undertake to inform the insurer of any change to any material fact. I understand that the information I provide will be used in deciding a suitable course of action by insurers.

I have read and understood the Privacy Policy

PI Claim Form

Introduction

A copy of this notification form will be emailed back to you once submitted and should be retained by you for your own records