Management Insurance Claims Form

Submit your claim

Page: Claims - Management

"*" indicates required fields

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).

Name

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