Has a claim officially been made, or is this notification of a potential claim? * — Please Select — Claim made Potential claim
What treatment was carried out? *
Summary of the circumstances *
Note any injuries that have been sustained. *
How was the consultation form completed? * — Please Select — Verbally Electronically Paper copy Consultation form not completed
If provided, how was after care advice given? * — Please Select — Verbally Electronically Paper copy After care advice not provided
Select refund status * — Please Select — Requested by client – not given Requested by client – given Offered to client – not taken Offered to client – taken Refund not discussed
Supply any information regarding refunds, including amounts. *
Summary of the circumstances *
List the names of any alleged responsible person and their status within the business. *
Provide the dates for the claim being made *
Provide any further information you wish to make us aware of as part of the claims notification (including any estimate losses) so that we can relay to the Underwriters. *
Summary of the circumstances *
Please list below all details you have relating to them *
List Police details below including any crime reference number. *
Provide any further information you wish to make us aware of as part of the claims notification (including any estimate losses) so that we can relay to the Underwriters. *
Summary of the circumstances *
Details of the employee involved in the claim *
Provide as much information as possible relating to injuries. *
Provide any further information you wish to make us aware of as part of the claims notification (including any estimate losses) so that we can relay to the Underwriters. *
Summary of the circumstances *
List all details you have relating to any third party, if you do not yet have this information then please advise TBC. *
Provide as much information as possible relating to injuries. *
Provide any further information you wish to make us aware of as part of the claims notification (including any estimate losses) so that we can relay to the Underwriters. *
Summary of the circumstances *
State below any actions you may have taken in order to limit the loss *
Provide details, inclusive of value or age (or both) for all items involved in a claim. Evidence of this will also be required from the Insurer. *
List all Police details below including any crime reference number. *
Summary of the circumstances *
Your Annual Turnover (£) *
Provide as much information relating to estimated losses so that we can relay to the Underwriters, and the company details/purpose for each loss. *
Provide any further information you wish to make us aware of as part of the claims notification.
Provide the start and end dates of the period you wish to claim for *
