Claim Form - Woodina Underwriting Agency

A. Insured Details
Name of the Insured
Policy Number
Insured’s contact person
Telephone
Email
B. Claim Details
a .Name of claimant/potential claimant.
b. Describe specifically the work you performed for the claimant.
c. Provide the full name/s of the person/s who performed the work.
d. Is that person/s an employee or sub-contractor?
e. What date/s was that work performed?
f. What date/s did any specific incident occur?
g. What is the precise nature of the claim (i.e. the claimant’s allegation) or the fact or circumstance that might give rise to a claim?
h. Please provide the date upon which you first became aware of the claim or circumstance which might give rise to a claim.
i. Have you ever received a letter from a lawyer representing the claimant? If so, please provide a copy.
j. What are your defences to the claim?
k. Were there any witnesses to the incident? If so, please provide their full name/s and contact details where known.
l. Has the claimant demanded compensation? If this was in writing, please provide a copy.
m. What compensation is the claimant seeking, if any?
n. How do you assess the claimant’s loss, if any?
o. What date did the claimant’s alleged loss occur, if any?
C. Complete below for property damage claims only
a. Is the claimant requesting you undertake repairs or further work?
b. In your opinion, are any of those repairs or further work urgent?
c. Do you have any suggestions of alternative, reasonably priced and experienced tradesmen to rectify this work?
Name
Position:
Date
Date Format: MM slash DD slash YYYY
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A. Insured Details

B. Claim Details

C. Complete below for property damage claims only

Woodina Underwriting Agency Pty Ltd

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