Professional Indemnity                              

Claim form

Zurich Insurance Company Ltd. (Singapore Branch) (the “Company”) does not admit liability by the issue of this form. It has been issued to assist the insured to notify a claim under a professional indemnity policy.

   Claim number	     (Zurich use only)

Important information
•    Do not admit liability.
•    Make sure you give us all the details about your claim. Attach a separate sheet if you have insufficient space on this form.

1   Policy details

Policy holder (the company who purchased the policy and in whose name the policy is held)

The policy number

The policy year/period

Is there any other insurance that may be applicable to the notification?	Yes	No
If you answered 'Yes' to the above question, please provide details

Insurer

Policy holder

Type of insurance

Period of insurance

3   Your contact details

Name

Address 	

Phone number  	 	 	 	Fax number

Mobile 	 	 	 	Email address

2   Important notice – Please provide the following documents

1.    Any written demands,

2.   Correspondence relating to that demand,

3.    Any contract which is in issue,

4.    If claim is against a subsidiary company, provide details on ownership structure of subsidiary.

Has this matter been notified to that insurer?	Yes	No

4   Details of claim

Date reported to you              /              /

Date incident occurred or work performed or completed

         Incident reported by

Incident reported to

What is the basis of the claim (or potential claim) against you?

When were you first aware that a claim may be made against you?

Was the claim made in writing? 	
 	 	 	
 	 	 	 	 	Yes 	 No	
Was the claim made verbally? 	 		
          		 		Yes 	 No	

If 'Yes', please provide details of any conversations, when they occurred and whom they were between

What is the amount claimed against you?  $

Please provide your comments regarding the allegations

         Summary of claim

List of documents attached

1.

2.

3.

4.

5.

6.

7.

8.

										           
                                                                                                                                                                                                         Professional Indemnity Claim Form – Pg 2 of 3

 5   Declaration
•	I / We hereby declare that all the information and particulars given above are true and complete to the best of my/our knowledge and belief and they are made without reservation of any kind.

•	I / We hereby acknowledge, consent and agree that –

i.	the Company may collect, use and disclose all personal data provided or as may be provided by me/us and through other sources as the Company deem relevant from time to time for the purposes as contemplated in this form including but not limited to policy servicing, processing, handling, administering, claims investigations, claims analysis, fraud evaluation, prevention and control, and/or any work put towards settling my/our claim with the Company or other insurers;  

ii.	the Company may disclose the personal data to third parties (whether in or outside Singapore) including but not limited to consultants, fraud detection agencies, the General Insurance Association and its members, regulators, law enforcement bodies and government agencies and/or authorities for the purposes as set out in this form; 

iii.	the personal data protection clauses herein (“DPC”) are not exhaustive. By signing this form, I/we declare that I/we have read, understood and agreed to be bound by the prevailing Personal Data Protection Policy available at http://www.zurich.com.sg/pdpa (“Data Protection Policy”) which is to be read together with the DPC. If there is any discrepancy between the DPC and the Data Protection Policy, the DPC shall prevail only to the extent of the discrepancy;     

iv.	if I / we provide third parties’ personal data (e.g. information of the life assureds, insured persons, beneficiaries, beneficial owners, dependents, spouse, children, parents, siblings, customers, prospects, payees and/or employees) to the Company, I / we represent and warrant to the Company that prior consents have been obtained from each of the third parties for the collection, usage, disclosure and processing of their personal data in the manner as set out above and the Data Protection Policy; and

v.	I / We shall indemnify the Company for all losses and damages which may be suffered by the Company arising out of the breach of the declarations, representations and/or warranties herein.

Name & Signature (with company’s stamp, if applicable) 	               Date
 	 	      /              /

										         Professional Indemnity Claim Form – Pg 3 of 3