Notify a Claim or Circumstance

Complete and submit form online

STRICTLY CONFIDENTIAL

LAW PRACTICE DETAILS

Type of law practice

SolicitorBarrister

Law practice entity name and Trading name

Only include Trading name if different from law practice entity name.

Address (main office)

Number and street | suburb or town | state | postcode

Contact person name

For LPLC to obtain additional information

Email

Contact person email address. A copy of this form, once submitted, will be automatically emailed to this address.

Phone

Best contact number

CLAIMANT DETAILS

Full name of claimant or possible claimant

Address of claimant or possible claimant

Number and street | suburb or town | state | postcode

Full name and address of claimant or possible claimant’s solicitor

BRIEF DETAILS OF (a) CLAIM OR (b) CIRCUMSTANCE

Has a claim for compensation or damages been made or intimated?

If Yes go to (a) Claim. If No go to (b) Circumstance.

YesNo

(a) Claim

A claim is a demand for, or assertion of a right to, civil compensation of civil damages or an intimation of an intention to seek such compensation or damages.

Date claim made or intimated

Short description of the nature of the allegations made or anticipated.

File Upload

Attach copies of any supporting documents detailing the claim (eg copy of letter of demand, legal procedings. NOTE: All files must be uploaded simultaneously. 10MB total limit. .doc .xlsx .jpg .txt .pdf .ppt file types only.

Amount of claim or possible claim (if known)

Can be an approximate sum or 'unknown'.

(b) Circumstance

A circumstance is an incident, occurrence, fact or matter which may give rise to a claim.

Short description of the circumstance that may give rise to a claim

File Upload

Attach copies of any supporting documents outlining the circumstance giving rise to the notification. NOTE: All files must be uploaded simultaneously. 10MB total limit. .doc .xlsx .jpg .txt .pdf .ppt file types only.

When and how did the law practice become aware of the circumstance

Date DD/MM/YYYY and short description

PERSON(S) HANDLING THE MATTER AT THE TIME OF THE ACT OR OMISSION GIVING RISE TO THIS CLAIM OR CIRCUMSTANCE

Name(s)

Full name(s)

In which State/Territory office did the alleged act or omission occur?

TOP-UP INSURANCE

Does your law practice hold top-up insurance that may respond to the claim or circumstance?

YesNo

You should notify top-up insurers of any claim or circumstance, however small.

Notice to LPLC does not constitute notification to top-up insurers. Separate notification should be arranged through your insurance broker.

ACKNOWLEDGEMENT AND CONSENT

Name of person submitting this form

Full name.

Position held in law practice

Phone

Best contact number

Email

Email address of person submitting this form. A copy of this form, once submitted, will be automatically emailed to this address.

Acknowledgement and consent

To the best of my knowledge the information in the form is true and correct.
I acknowledge that LPLC receives this form without prejudice to its right to determine indemnity pursuant to the terms of the law practice's policy of insurance with LPLC.
I consent to the collection, use and disclosure of the information disclosed in this form in accordance with LPLC's Privacy Policy.

Check then submit

Once successfully submitted via the button above, an acknowledgement message will appear in the browser window of the person who submitted the form.

Receipt of the form will also be confirmed by LPLC via return email to the email address nominated in the form.

Please contact us if you receive an error message after submitting this form at [email protected]

Download and complete form as a fillable pdf

IMPORTANT

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All entries will be lost if the form is completed in a browser view without being first downloaded.

Please contact us if you need any further assistance.

IMPORTANT: Download before completing, saving and sending to LPLC.

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