Professional Indemnity Claim
The issue of this form is NOT an admission of liability on the part of the Company. Please answer all questions fully and return form without delay to
ALLIANZ NIGERIA INSURANCE PLC
Full Name of the Insured
*
Address of the Insured
Contact person
Policy No
*
Telephone Number
*
E-Mail:
*
Occupation or Business
2
Details of Claimant
Full name of the Claimant or potential Claimant (i.e the party making the claim or potential claim against you or the firm/company)
Address of the Claimant
3
Details of Insured's Retainer/Contract
What were you retained/contracted to do
Was your retainer/contract for services evidenced in writing
please select
Yes
No
if so , please attach a copy
If not, please provide appropriate particulars of the date of the retainer/contracts and its terms
When did you perform the workout of which the claim arises or may arise
Who is the person within the firm/company, who actually performed the work or against whom the claim or potential claim is principally directed
What is that person's title, duties and contact details
4
Details of Claim or Circumstance
What is the precise nature of the claim (i.e the claimant's allegations) or the factor circumstance that might give rise to a claim
Have proceedings commenced
please select
Yes
No
if so , please attach a copy of the court documents
On what date did you first become aware of the claim or the factor circumstance
Was the first intimation of a claim oral or in writing
please select
Yes
No
If in writing, please attach a copy
If oral, please give a “first person” account of the conversation, (i.e “He said”, Ï said”)
What amount, if any, is claimed
If known, what does that amount comprise
5
Details of Insured's Response
What are your comments in response to the claim or the factor circumstance that might give rise
What are your comments on the quantum of the claim and what is your estimate of your potential monetary Liability, if any, to the claimant
Are there additional details about which you wish to advise, or which may be of interest to an insurer, so that insurer will have a better understanding of this matter
please select
Yes
No
If so, please provide details along with supporting documentation
Have you instructed a solicitor or other lawyer to act for you
please select
Yes
No
If so, what is that lawyer's name, firm, address and charge out
Lawyer's Name
Lawyer's Firm
Lawyer's Address
Declaration
I/We
Position of the insured and on behalf and on behalf of the insured declared above answers to be true and correct AND acknowledge that the insurer may make its decision on indemnity having regard to these answer
Signature
Date
Submit
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