WidgetGuard Insurance Brokers

Claim Notification - Professional Indemnity Claim Form

Please provide your details below.

Please fill in the details below as accurately as possible to help us progress with your claim.

Insured name

Phone

Policy number

Claimant/Potential Claimant Details

Claimant Name

Claimant Address

Claimant Phone

Claimants Solicitors (if any)

Information Required

Who were you retained by / Who did you contract with?

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

When did you perform the work out of which the Claim has arising or may arise?

Please provide the name of the person who performed the work

Claim or Circumstance

What has been claimed against you or what fact or known circumstance might give rise to a claim?

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

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

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

Was the Claim or an intimation of a Claim made verbally?

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

Insurance history

Have you had any claims in the last 5 years? (YES / NO If Yes, provide details.)

Has any Insurance Company refused to renew or cancelled/terminated a policy? Has any Insurance Company refused a claim? (YES / NO If Yes, provide details.)

Have you been convicted of or had any fines or penalties imposed for any criminal offences in the last 10 years? (YES / NO If Yes, provide details.)

Additional information (optional)

Do you have a supporting quote, invoices or photo?s that will assist us to lodge your claim with your insurer? (If yes ? please email these to [email protected]).

WidgetGuard Insurance Brokers, where tradition meets innovation.

Whether you seek coverage for your zeppelin fleet, enchanted artifacts, or mundane minivans, our brokers - armed with laptops and espresso machines - stand ready.
We're not just about policies; we're about peace of mind.

So, dear client, step into our oak-paneled office, sip your tea, and let us weave a protective cocoon around your dreams.
Because at WidgetGuard, we don't just insure widgets; we guard legacies.