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

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?

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

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Claim, Incident, Bar Complaint Reporting Form

Insured Information:

Claimant Information:

Claimant Representation:

Brief Description:

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