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To be completed by the Authorised Person(s) set out in the Proposal Form / Renewal Questionnaire. The Insurer cannot accept submissions from unauthorised contacts. We require the information set out in this form in order to check whether what you are reporting is covered by your Policy and for compliance with Practice directions and Pre-action Protocols issued and approved from time to time by the Civil courts.

If you require more space for any of the answers, please use the ‘Further comments’ field in each section. If you need any help completing this form, please contact Healthcare Protection for guidance on 800905727.

Please email any additional information to [email protected]

Claim notification

All questions in this section must be answered as fully as possible (use ‘Further comments’ if necessary). Your claims representative will work with you to understand the basis of your claim and obtain the necessary information to validate coverage.
* denotes a required field.

Your details

Title *

First name *

Last name *

Position *

Preferred contact number *

Email address *

Policy details

Insured *

Policy number *

Claim details

Please enter details of claim and upload copies of all relevant correspondence/ documentation

To upload relevant reporting documentation please use the document upload tool below towards the end of the form.

Enter details below *

To insert a line break please use Shift+Return keys together.

Amount of claim (if known)

Date of receipt of first communication or verbal complaint (If applicable)

Patient's details

Name

Patient's gender

Patient's date of birth

Patient reference number at the practice/ hospital (if applicable)

Patient's present condition and prognosis (if known)

To insert a line break please use Shift+Return keys together.

Practitioner(s) and other parties involved in the incident/ treatment:

Practitioner / other party 1

Name and title

Employee / independent contractor

Employer name

Professional body (please specify) registration number

Indemnifier / insurer

Policy number

Cover in place

Practitioner / other party 2

Name and title

Employee / independent contractor

Employer name

Professional body (please specify) registration number

Indemnifier / insurer

Policy number

Cover in place

Practitioner / other party 3

Name and title

Employee / independent contractor

Employer name

Professional body (please specify) registration number

Indemnifier / insurer

Policy number

Cover in place

Practitioner / other party 4

Name and title

Employee / independent contractor

Employer name

Professional body (please specify) registration number

Indemnifier / insurer

Policy number

Cover in place

If there are additional parties involved, please provide information under the Further comments section below

Date of Writ/ Summons / Claim Form / Court proceedings (If applicable)

Date of Service

Method of Service

Place of Service

Plaintiff's name if different to the patient

Plaintiff's relationship to patient

Further comments and supporting documentation

Please enter any further comments

To insert a line break please use Shift+Return keys together.

Important note

We may request copy correspondence pertaining to the adverse incident, together with redacted documentation and Medical/ Dental records relating to the treatment in question to be sent to us securely.

The Insured is respectfully reminded of the Policy’s terms and conditions, and accordingly that no details of the Policy may be disclosed, nor may liability be admitted, arrangement, offer, promise or payment be made, or cost or expense incurred by the Insured without the written consent of the Insurer.

The Insured’s attention is also drawn to the requirement under the Policy to provide Healthcare Protection with IMMEDIATE NOTICE OF CLAIMS OR CIRCUMSTANCES which may give rise to a claim; notice must be made as soon as reasonably practicable within the policy period (or within 30 calendar days of the policy expiring). Accordingly, if the Insured is unable to complete all sections of this form, this should not delay its dispatch to the Insurer and any further information or material can be provided as soon as possible thereafter.

Declaration

Please check the box below *

On behalf of the insured I declare that to the best of my knowledge and belief these particulars are complete and correct and I have not withheld or mis-stated any material information which may directly or indirectly affect this claim.

Notification of claim

Claim notification

Your details

Policy details

Claim details

Further comments and supporting documentation

Declaration

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