Claim, Incident, Bar Complaint Reporting Form Scroll Down Claim: Receipt by an Insured of a demand for money or services (including the service of suit or the institution of arbitration proceedings) against the Insured from one other than that Insured. Incident: Act or omission which may give rise to a Claim. Insured Information:Insured Firm:*Reported By* First Last Email* Phone*Firm Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Disciplinary Complaint? Check here if you are reporting a disciplinary complaint Insured Attorney(s) Involved with case.Date of Insured's First Knowledge of Claim/Incident/Bar Complaint*Date of Alleged Negligence*Has a suit been filed?Has a suit been filed?YesNoDate Served*Venue & Cause NumberClaimant Information:Name of ClaimantClaimant Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Claimant PhoneClaimant Representation:Claimant's Current RepresentativeRepresentative's PhoneRepresentative's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Brief Description:Give a Brief Description of the Representation/Alleged Negligence giving rise to this Claim/Incident/Bar Complaint. **Do not enter confidential information in this field.** Confidential information and supporting documentation can be sent later via email. Further instructions will be provided after this form is submitted.Brief DescriptionCAPTCHA
