Professional Insurance Claim

Type of Insurance

Please select type of Insurance Claim*

Insured Details

Are you registered for GST?*
Are you entitled to claim on input tax credit on this policy?

Claim Details

If the question is not applicable please mark as N/A
Please pick the category which best describes the claim or incident you are notifying.
Was your retainer or contract confirmed in writing?

Please attach document (bottom of form)

DD slash MM slash YYYY
How were allegations against you made?

Please provide attachments as necessary (bottom of form)

Have you received a request to attend any Enquiry into the circumstances notified in this report?

Please attach copy of the request. (bottom of form)

Cyber Event Details

Have you been notified by Law Enforcement or your Bank about a potential data breach?
Are you being requested to perform a Payment of Card Industry (PCI) Forensic Investigation?
Do you believe sensitive data has been compromised and that you need to confirm / deny that a data breach has taken place?
Have you received a written demand or notice of claim from a third party seeking compensation or other legal remedy?

Payment Details

If your claim is accepted, to ensure a prompt settlement, would you like the funds deposited into your Bank Account?

Declaration

I/We declare the above answers to be true AND acknowledge that the Insurer may make their decision on indemnity have regard to these answers
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ATTACH RELATED DOCUMENTS

Please include all related documents to this claim
Drop files here or
Max. file size: 4 MB, Max. files: 8.


    For large files please email to claims@abcountrywide.com.au

    This field is for validation purposes and should be left unchanged.

    © 2022 AUSTBROKERS COUNTRYWIDE Countrywide Insurance Group Pty Ltd ABN 49 625 733 539 AFSL 511363

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    By purchasing online:

    •  You are expected to self-manage your policy.
    •  There is no advice provided by Austbrokers Countrywide.
    •  You will need to manage your own claims directly with COVERMORE by calling 1300 728 822.
    •  If you need to make changes to the policy, you will need to contact COVERMORE on 1300 728 822.

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    By purchasing online:

    •  You are expected to self-manage your policy.
    •  There is no advice provided by Austbrokers Countrywide.
    •  You will need to manage your own claims directly with CHUBB by calling 1800 803 548.
    •  If you need to make changes to the policy, you will need to contact CHUBB on 1800 803 548..

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    By purchasing online:

    •  You are expected to self-manage your policy.
    •  There is no advice provided by Austbrokers Countrywide.
    •  You will need to manage your own claims directly with EMERGENCE by calling 1300 799 562.
    •  If you need to make changes to the policy, you will need to contact EMERGENCE on 1300 799 562

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    1. Engineering & Construction Industry Project Manager

    2. Information Technology Project Manager

    3. Other Project Manager (including white collar, training, government, and change management)

     

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    By purchasing online:

    •  You are expected to self-manage your policy.
    •  There is no advice provided by Austbrokers Countrywide.
    •  You will need to manage your own claims directly with Austbrokers Life Solutions by calling 1300 161 635.
    •  If you need to make changes to the policy, you will need to contact Austbrokers Life Solutions on 1300 161 635.

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