Indemnity Insurance Claim Form

Indemnity Insurance Claim Form

Submit your public or products indemnity claim. Please complete all relevant sections to ensure prompt assessment.
Important notice

You must answer all questions honestly and fully.

To help us process your claim quickly, please answer all questions as completely as possible.If a question is not relevant to your situation, please write "N/A".
Section 1: Claimant / Business Details
Business Name
Contact Person Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: 04 00000000.
Email Address
Indemnity sought: Indemnity being sought as you have received a claim for loss or action against you.
Notification Only: A notification is when an insured discloses the facts that might give rise to a claim.
Section 2: Policy Details
Insurer
Policy Number
Period of insurance

Section 3: Incident Details
Date of incident

DayMonthYear

MinutesAM/PM Option
Location of incident

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
State
Description of what happened
Is there a Letter of Demand?
Have you received a Statement of Claim or any other correspondence from the Courts?
Are there any other files relating to this incident that you would like to upload?
File Upload

Cancelof

Section 1: Claimant / Business Details