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Claim Form

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 a Partner/Director/Principal of the Insured. All questions must be answered as fully as possible. * Denotes a required field

Details of Person(s) Claiming Against You (Claimant)

Include your Suburb, State and Post Code

Details of Claim

What was the work you were contracted (asked) to do?
When the work was carried out
Who carried out the work?
Eg treatment proposal, quotation?

When did you first become aware of the complaint or the situation that a claim has risen from?
How were you told?

Provide your comments on the claimant’s allegations
What is the amount claimed?
Provide your comments on the amount of the claim
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.
Type your name