Professional Insurance Claim

Type of Insurance

Please select type of Insurance Claim*

Professional Indemnity

Management Liability

Directors and Officers

Cyber Liability

Pharmacy

Insured Details

Policy Number

Client Reference Number

Membership Number*

Insured Name

Member Name*

Business Name

Business Name (If applicable)

Business Type Pharmacy

Insured Occupation

Insured's Address

Insured's Email*

Insured's Phone Number*

Are you registered for GST?*

Yes

What is your Australian Business Number (ABN)?

Are you entitled to claim on input tax credit on this policy?

Yes

Input Tax Credit %

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.

Dispensing Issue

Breach of Privacy

Issues around pharmacist-patient interaction

Pharmacy Legislation/Regulation

Notification/Request from relevant authority

Unprofessional Conduct

Please select Dispensing Issue

Please select Breach of Privacy Issue

Please describe other breach of privacy issue

Please select Pharmacy Legislation/regulation Issue

Please select Unprofessional Conduct Issue

What were you retained or contracted to do which may give rise to this claim or possible claim/s?

Was your retainer or contract confirmed in writing?

Yes

Please attach document (bottom of form)

Please provide appropriate details.

Please explain what has happened.

When did you perform the work from which this incident or possible claim arises?

Date when you first became aware of the incident or possible claim against you and what brought this to your attention

Name of the party who is or may be claiming against you

How were allegations against you made?

In Writing

Verbal

Please provide attachments as necessary (bottom of form)

Please give an account of the conversation

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

Yes

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

What are your views regarding these allegations?

What action do you consider should be taken?

What is your estimate of the maximum claim if everything goes against you?

Cyber Event Details

Please explain the circumstances of the Cyber Event.

Date when you first became aware of a claim or possible claim against you and what brought this to your attention

Have you been notified by Law Enforcement or your Bank about a potential data breach?

Yes

Are you being requested to perform a Payment of Card Industry (PCI) Forensic Investigation?

Yes

Do you believe sensitive data has been compromised and that you need to confirm / deny that a data breach has taken place?

Yes

Have you received a written demand or notice of claim from a third party seeking compensation or other legal remedy?

Yes

Third Party Contact Name

Third Party Business Name

Phone

Business Address

Involvement

Payment Details

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

Yes

Bank Name

Account Name

BSB

Account Number

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

I Agree

Hidden

Any other comments which you consider pertinent?

ATTACH RELATED DOCUMENTS

Please include all related documents to this claim

Attach Files (8 Files allowed. Max size per file is 4MB).

Drop files here or

Max. file size: 4 MB, Max. files: 8.

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

Comments

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