Online Notification

Solicitors PI Notification Form
Email address *
Confirm Email address *




Name of firm:


Address

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country


Telephone number:


Contact:


Policy Reference:


Broker details:
(if applicable)


Claimant details:


Date instructed:

MM 		/
DD 		/
YYYY


Date terminated:

MM 		/
DD 		/
YYYY


Brief details of retainer:


Has a formal claim been made against you? *
 Yes 
 No 


Details of how the claim arose and the allegations made:


Date of alleged act:

MM 		/
DD 		/
YYYY


Date of first awareness of potential claim:

MM 		/
DD 		/
YYYY


Have proceedings been threatened or commenced?
 Yes 
 No 


Do you feel in any way responsible or liable?
 Yes 
 No 


What is the possible quantum?


Any other comments:







 
5th Floor Minster House
42 Mincing Lane
London EC3R 7AE
  
tel: 0870 839 0839
fax: 0870 839 0939
e-mail

 
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