Claim, Incident, Bar Complaint Reporting Form

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

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?

Yes
No

Date Served*

Venue & Cause Number

Claimant Information:

Name of Claimant

Claimant Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Claimant Phone

Claimant Representation:

Claimant's Current Representative

Representative's Phone

Representative'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 Description

CAPTCHA

Claim, Incident, Bar Complaint Reporting Form

Insured Information:

Claimant Information:

Claimant Representation:

Brief Description:

Have a Question?

Products

Our Company

Resources