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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: 1 of 2 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: 2 of 2 Professional Indemnity Claim Form I LGIS Copyright©2016 Date: