Surveyors professional indemnity insurance claim notification form

Details of the insured

Practice name*

Main office address*

Postcode*

Main office telephone number*

Main office fax number

Contact email address*

Services Provided

Name of client (or claimant)

Date services rendered to your client: Commenced

Date services rendered to your client: Completed

Terms and Conditions of your engagement and nature of services rendered

Were any specialist consultants used?

No Yes

If 'Yes', please give details and a note of their duties together with how and by whom they were appointed, i.e. the contractual "chain".

IMPORTANT If consultants/sub consultants were involved, it is essential that they are advised to notify their own liability insurers.

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 you or loss incurred by you:

Has any intention to claim against you been expressed?

No Yes

If 'Yes', by whom and in what circumstances

Details of loss and/or damage

Does the loss and/or damage arise as a result of defective workmanship or as a result of incorrect or defective advice/design etc? Please give details:

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

Personal injury and/or damage to property (if appropriate)

If any personal injury and/or damage to third party property is involved, have appropriate liability insurers been notified?

No Yes

Have the liability insurers accepted the claim under the appropriate policy?

No Yes

If 'No', please clarify how the injury and/or damage falls to be your responsibility:

Your Details

Your name*

Your position*

Attach additional information

If you would like to attach more information, please upload your file here.

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 »

Surveyors professional indemnity insurance claim notification form

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