Notification of Claim

Notification of Circumstance which could bring rise to a claim

Everest Medical Indemnity is a registered trading entity of Everest Risk Group Pty Ltd and Corporate Authorised Representative (No 276869) of Insurance Advisernet Australia Pty Ltd (AFSL 240549)
CLAIMS MADE POLICY

This Claims Notification is for a Claims Made Policy. This means that the policy only responds to:
- Claims first made against you and notified to the Insurer during the policy period arising from events after any retroactive date stated on the policy, and
- Events of which you first become aware during the policy period that could give rise to a future claim provided that you notify the Insurer during the policy period of the circumstances of such events and they arose after any retroactive date on the policy.
When the policy expires, no claims can be made on the policy even though the event giving rise to the claim may have occurred during the policy period.

It is therefore advisable to renew the policy each year on a Claims Made basis with retroactive cover for past activities. All known claims or circumstances should be disclosed to your current insurer before the policy expires to avoid the potential of uninsured losses.

IMPORTANT NOTICES

Insurers may not accept notification for a number of reasons:
- Insufficient Information (make the notification as specific in detail as you can)
- Late notification/non-disclosure
- No coverage exists for the matter
In the above circumstances Everest Risk Group will advise you of your options

Remember that you should not make any admission of liability without the express consent of the insurer
1. Please send us all relevant correspondence in the first instance, not the entire file
2. Please do not delay forwarding correspondence in particular where matters will proceed to conciliation, arbitration or dispute resolutions protocols
3. Do not provide information to the third party (client) which may prejudice your defence. If in doubt, please refer to Everest Risk Group
4. Be aware the written notification has to be made within the timeframe set out in the policy and always before the expiry date of the current policy
5. If any responses require further elaboration, please provide an addendum
6. Complete this form or Phone 02 9241 1970 for assistance
PRIVACY STATEMENT

We are committed to protecting your privacy. We only use the personal information you provide to us to quote on and insure your risks. We only provide personal information to our underwriters and reinsurers (and their representatives) and those we appoint to assist us with claims under your policy. We will not trade, rent or sell your information.

If you do not provide us with complete information, we cannot properly quote for your insurance and we cannot insure you or assist you at claims time. You can check the personal information we hold about you at any time.

Insured Details
Insured Name/Company/Firm*
Main Address of the Firm*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Details of person with the most knowledge of the matter:
Contact Name:*

First NameLast Name
Contact Email Address:*

Confirmation Email
Contact Phone Number*

Area CodePhone Number
Insurer/Policy number if known

Details of the Claim or Circumstance
Full name of the claimant/potential claimant*
When did you become aware of the circumstance or claim?*

DayMonthYear
Claimant Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date(s) of attendance for care or date of incident: *
Please provide details of the claim or circumstances that might give rise to a claim: *
What, if any, compensation is claimed?*
Please provide any additional information that may assist our understanding of the matter:
Please attach the following (if available):
1. Letter of demand
2. Court proceedings (all documents filed)
3. Clinical notes
4. File notes of any conversations concerning the claim
You can upload multiple files:

Upload a File

Cancelof

GST
Are you registered for GST?*

YesNo
What is your ABN?*
Have you claimed or intend to claim any input tax credit on the GST component of the premium applicable to the policy?*

YesNo
Will you be claiming an amount less than 100%?*

YesNo
What percentage will you be claiming?
Please enter a whole number

Declaration
I hereby declare, for and on behalf of the Insured, that the foregoing statements are true and correct:
Signature
Name*

First NameLast Name
Title*
Date*

DayMonthYear
Should be Empty:

Notification of Circumstance which could bring rise to a claim