Level 1, 2 Wellington Parade, East Melbourne. 3002.
ph: 03 9235 5255 fax: 1800 633 073
email: enquiries@prorisk.com.au web: www.prorisk.com.au

Professional Risk Underwriting Pty Ltd ABN 80 103 953 073. AFSL 308076.

NOTIFICATION OF CLAIM OR POTENTIAL CLAIM FORM

Important Notice:
•	This form is to be completed and signed by a Principal of the Insured when notifying a Claim or a fact or circumstance that has the potential to give rise to a Claim.
•	All questions must be answered in full. If there is insufficient space, please provide further details on the Insured’s letterhead.
•	Please attach all relevant correspondence and documentation.

A.	INSURED
Name:  Address: Contact Person: Telephone: Facsimile: Email:
Policy No.:

Period of Insurance:	From:	To: Broker:
Telephone: Facsimile: Email:
Are you registered for GST Purposes:	Yes	❑	No	❑
If so what is your ABN:

What percentage (if any) of GST on premium has been applied as an
Input Tax Credit?	%

B.	CLAIMANT / POTENTIAL CLAIMANT
Name: Address: Telephone: Facsimile: Email:
Claimants Solicitors:	(if any)

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C.	INSURED’S RETAINER / CONTRACT
1.	Who were you retained by / Who did you contract with?

2.	What were you retained / contracted to do? (If the retainer / contract was in writing, please provide a copy)

3.	When did you perform the work out of which the Claim has arisen or may arise?

4.	The name of the person who performed the work:

D.	CLAIM OR CIRCUMSTANCE
1.	What has been claimed against you or what fact or circumstance might give rise to a claim?

2.	When did you first become aware of the Claim or the fact or circumstance that might give rise to a Claim?

3.	When was the Claim or an intimation of a Claim first made against you?

4.	Was the Claim or an intimation of a Claim made in writing? (If Yes, please provide a copy)

5.	Was the Claim or an intimation of a Claim made verbally? (If Yes, please provide a copy)

6.	What is the likely quantum of the Claim or potential Claim?

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E.	YOUR COMMENTS
1.	What are your comments in response to the Claim or in respect to the potential claim?

2.	Do you have further information concerning this matter, which may be of assistance to Insurers?

DECLARATION:

I declare that:

•	I am authorised on behalf of the Insured(s) to make this Declaration.
•	The information in this Form is true and correct and I have not withheld any relevant information.
•	I have read and understood the ProRisk Privacy Statement and I consent to ProRisk using the personal information in this Form for the purposes of investigating and handling any Claim or potential Claim against the Insured. I consent to ProRisk disclosing the personal information to third parties involved in the claims process, such as the Insurers, lawyers, claims adjusters and others appointed by ProRisk or by the Insurers.
•	Where I have provided information about another individual, I declare that the individual has been made aware of that fact and of the ProRisk Privacy Statement.

Signature: Name:
Position:

Date:

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