Management Insurance Claims Form

Submit your claim

Page: Claims - Management

"*" indicates required fields

URL

This field is for validation purposes and should be left unchanged.

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

Insured name*

Email*

Phone*

Policy number*

Insurance Product*

Is this a Management Liability Claim?*

Yes

Is this a Employment Practices Claim?*

Yes

Claimant/Potential Claimant Details

Claimant Name*

Claimant Phone*

Claimant Address*

Claimants Solicitors (if any)*

Claim or Circumstance

Date of incident out of which a Claim has been or might be made against you.*

Date you first became aware that a set of circumstances existed, which may result in a Claim being made against you.*

Date you first received a notice of intention from party to make a Claim (If in writing, please provide a copy).*

Have you received a demand for compensation in writing? (If Yes, please provide a copy). If No, please provide details of allegations made against you.*

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 claims@bruce.com.au).