Submit A Claim Form Online

To begin processing your claim

Please complete this form with as much detail as possible. Upon completion, a Claims Officer will be in contact to discuss the issue. This form must be completed by an Authorised Person on the Insured’s Policy. All questions must be answered as fully as possible.

Your Name *

Name of your Firm *

Contact number *

Policy No*

DETAILS OF PERSON(S) CLAIMING AGAINST YOU (CLAIMANT)

Full Name*

Street Address*

Suburb*

State *

Post Code *

Phone Number*

Email Address *

DETAILS OF CLAIM

What was the work you were contracted (asked) to do?*

Date (When the work was carried out) *

Technician (Who carried out the work?) *

Was the technician an employee or contractor? *

Was there a written contract between your business and the claimant (Eg treatment proposal, quotation?)?*

When did you first become aware of the complaint or situation that may give rise to a claim?*

How were you notified of the complaint or situation?*

Tell us in your own words how this situation came about (Describe the conversation with the claimant or your understanding of how your way may have given rise to the situation)*

Allegations (What is the claimant alleging has occurred?) *

Is there anything further you can tell us about the circumstances of this matter? *

Please upload any files relevant to your claim

Max. file size: 50 MB.
The maximum size for each file is 64MB.

I declare the above answers to be true AND acknowledge that Pacific International may make its decision on indemnity having regard to these answers. I acknowledge that in accordance with the terms of the policy with Pacific International I shall bear the cost of the policy excess and agree to payment within 14 days from the date of their request. I further acknowledge that, in accord with the terms of the policy, Pacific International shall be entitled to take over and conduct the defence or settlement of this claim.

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