Notification of Claim or Circumstance Form Home ClaimsNotify a Claim Lawcover’s policy requires immediate written notice to be given by the law practice of any claim or circumstance which may give rise to a claim. Complete and submit form online STRICTLY CONFIDENTIAL Please complete this form in its entirety as you will not be able to save your progress. The system will only save when the form is submitted. Date Day Month Year Notification Progress Step 1 Practice Details Step 2 Solicitor/ Claimant Details Step 3 Claim information Step 4 Acknowledgement Law Practice details Full name of Firm or Company Business or Trading name Law Society Practice Number Main address Suburb State Postcode Name of person completing the form Contact Name Email Position Phone (office) Phone (mob) Preferred contact for this claim (if different to above) Contact Name Email Position Phone (office) Phone (mob) Next Please only include the most accurate and relevant information. Please omit sensitive and/or personal information (including personal information of the claimant) not directly relevant to the claim Claim or Circumstance Details Solicitor Details: Name of the Principal or Supervising Principal whose alleged actions or omissions are the cause of this notification Name of Employee if his/her alleged actions are the cause of this notification Was any other Law Practice involved in this matter? Yes No If yes, please name the Law Practice Claimant Details: Name Was the claimant your Law Practice’s client in the transaction that is the cause of this notification? Yes No If no, please provide the name of your client(s) Did your Law Practice act for more than one party to the transaction? Yes No If yes, please name any other party for whom the Law Practice has acted Next Back Claim information: Date or range of dates when alleged act or omission occurred Date when Law Practice became aware of the alleged act or omission Has a claim for compensation or costs been made or intimated against your Law Practice? Yes No If yes, how was the claim made? Verbally Letter of Demand Service of Proceedings Other (please specify): If a demand has been made, please advise the estimated amount claimed (this can be a range of amounts) If a demand has been made, what date was it made? Has your Law Practice notified this matter to any insurer (including Lawcover) prior to last 1 July? Yes No If yes, please provide details To your knowledge, has the claimant made a complaint to the Legal Services Comissioner or Law Society concerning this matter? Yes No Brief summary of Alleged Act or Omission: Please provide a brief description of the circumstances which are the alleged cause of this notification. Please do not include any admissions or comments about liability; a solicitor will contact you to obtain full details after this notification is received. Next Back Acknowledgement By ticking the box at the end of this section, I acknowledge the following: I have checked the information provided in this form and to the best of my knowledge it is true, correct and complete. The information disclosed in this form is without prejudice to the rights of Lawcover to determine indemnity pursuant to the Lawcover PII policy. I consent to the collection, use and disclosure of information as set out in Lawcover’s Privacy Policy. Tick to acknowledge above statements Submit Click on SUBMIT above to submit your notification. Once successfully submitted, you will receive a copy of the notification form to the email address nominated. Receipt of the form will also be confirmed by a Lawcover Claims Solicitor.
