Errors and Omissions Professional Liability Insurance Program Claim Form Errors

							                                                                                      Errors and Omissions/Professional Liability
                                                                                                 Insurance Program Claim Form




 Errors and Omissions/Professional Liability Insurance
 Program Claim Form
 1.         Firm Name and Address
                                                                                                   Date Reported

                                                                                               Master Policy No.
                                                                                                    Certificate No.
            Telephone                                                                                              Fax
            E-mail

 2.         Name and position of person alleged to have committed error




 3.         Claimant’s Name and Address                                                          Claimant Lawyer’s Name and Address




            Telephone                                                                             Telephone

 4.         Did you receive a Statement of Claim or any other court documents?                                                      Yes       No
            If yes, when were you served?

 5.         When did you first become aware of the potential claim?
            If no, when did you first receive notice of a potential claim?

 6.         Type of product involved in alleged error.

            Name and address of provider involved.



 7.         Describe nature of error alleged to have been committed.




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                                                                                      Errors and Omissions/Professional Liability
                                                                                                 Insurance Program Claim Form




 8.         Describe nature of and estimated amount of damage or loss by the claimant.




 9.         Additional Comments which may be of assistance in handling this claim.




 (Use additional pages if necessary)                                                                                            Policy No. 418 380
 IMPORTANT NOTICE

                                                                        Contact Information

                                  Shumka Craig & Moore Adjusters Canada Ltd.

                                                                 Tel: 1-888-726-7333
                                                                  Fax: 1-888-870-7484
                                                                Email: EandOPro@scm.ca

    Please fax copies of any and all documentation related to this matter. Furthermore, include a copy of
             your certificate of insurance along with this form and the related correspondence.




 Reported by
                                                     (Print name)




                                    Person to contact at your office for
                                         additional information



      Signature                                                                                                Date Signed




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