Chancery PII

STRICTLY PRIVILEGED AND CONFIDENTIAL

SOLICITORS PROFESSIONAL INDEMNITY INSURANCE

CLAIM AND CIRCUMSTANCE NOTIFICATION FORM

Please answer all questions (or respond Not Applicable or Unknown as necessary)



1. Your Details – Policy Number
1.1 Insured / Insured Firm Name:
  Chancery Pii Policy Number:
1.2 Address:
1.3 DX:
1.4 Telephone Number:
1.5 Claims Handler at Insured / Insured Firm:
1.6 Email:
1.7 Name of firm from which claim arose (if different to above):
2. Claimant Details
2.1 Name of Claimant:
2.2 Address of Claimant:
2.3 Name of Claimant's Solicitors:
2.4 Address of Claimant's Solicitors:
2.5 DX:
2.6 Telephone Number:
2.7 Contact Name:
3. Insured / Insured Firm Fee Earner Details
3.1 Name:
3.2 Status:
3.3 Current Whereabouts:
3.4 Supervisor:
3.5 Other Staff Involved:
4. Retainer Details
4.1 Date of Instructions (dd/mm/yyyy):
4.2 Date Retainer Ended (dd/mm/yyyy):
4.3 Work Type:
4.4 Purpose of Retainer:
4.5 List all Clients under Retainer:
5. Claim or Circumstance which may give rise to a Claim - Details
5.1 Date when any member of your firm first became aware of the Claim, or Circumstance from which it arose if earlier (dd/mm/yyyy):
5.2 Date the Claim was first made against Insured / Insured Firm (dd/mm/yyyy)::
5.3 Date of your alleged act, error or omission or explanation of date of first awareness or discovery of the Claim or Circumstance (with explanation for selection of this date) (dd/mm/yyyy):
5.4 Background to Claim or Circumstance including chronology and details of all parties involved:
5.5 Specify details of the alleged act, error or omission for the Claim or Circumstance which is the subject of this notification (and provide supporting documents where possible (e.g. copy proceedings, pre-action notice letters, emails, telephone notes):
5.6 Do you consider that you are liable to the claimant or potential claimant?:
(please provide an explanation)
5.7 Is any other party or service provider liable or potentially liable?:
(If yes, provide an explanation)
5.8 Mitigation details:
(Explain steps taken or recommend to mitigate any Claim or Circumstance)
6. Quantum Details
6.1 Specify the quantum of Claim or amount in dispute claimed by the claimant or your estimate of the maximum value of the Circumstance on a worst outcome basis:
(List of heads and amount of claim)
6.2 Provide your quantification of the Claim or amount in dispute or value of the Circumstance taking into account your own estimate of your firm’s potential liability i.e your realistic view of the likely outcome before application of your policy Retention or Excess:
(List heads and amount of claim)
7. Your Papers
7.1 Have you retained your file or a copy? (state which):
7.2 Does the Claimant/Claimant’s Solicitor have the file or a copy? (state which):
7.3 Are you exercising a lien or do you intend to do so?:



Please attach copies of all relevant documentation including any letters of claim, pre-action notice letters or proceedings etc. and if you need to expand upon any of the above answers please do so on an additional sheet.

To the best of my knowledge the information contained in this form is complete and correct.




  File 1 (PDF only):
  File 2 (PDF only):
  File 3 (PDF only):
  File 4 (PDF only):
  File 5 (PDF only):



  Signed
  Please enter the numbers and letters on the image
 



This form must be signed by a Partner or Principal of an Insured Firm, or if submitted electronically, the transmission of the form will be regarded as having been approved and sent by a Partner or Principal of Insured Firm.