Download Professional Indemnity Claim Form

Professional
Indemnity
Claim Form
Return to: [email protected]
or mail to LGIS Liability, PO Box 1003, West Perth WA 6872
Do not give this claim to the claimant – to be completed by council officer only
Council:
Date when claim was made
(or notice of possible claim received):
State whether verbal or written:
Claimant’s details
Name: (organisation)
Ref number:
Claimant details
First name:
Last name:
Male
Female
Postal address (required):
Contact number:
➤➤ Is this person(s) making a claim on behalf of themselves or another party?
Yes
No
If other party, please state name of other party:
Details of claim/enquiry:
➤➤ Detail any action taken by you following notification:
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Professional Indemnity Claim Form I LGIS Copyright©2016
The information contained in this form has two (2) purposes:
1. To assist in identifying whether you have a legal liability.
2. To maintain detailed records for Risk Management purposes.
Please ensure that all relevant details and attachments are included in/with this form i.e.
Copies of contract agreements
Copies of inspection and/or maintenance programs (if applicable)
Copies of hire agreements
Copies of plans
Photographs (if available)
If you have any queries regarding this form, please do not hesitate to
contact the liability claims department team on 9483 8888
Declaration
I (name, title):
do hereby declare that the above statements and answers are true and correct in every particular of this claim and that
no information has been withheld or concealed.
Declared at:
Signed by:
For and behalf of
(name of Council):
Signature:
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Professional Indemnity Claim Form I LGIS Copyright©2016
Date: