Claim, Incident, Bar Complaint Reporting Form Scroll Down "*" indicates required fields 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? 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 PhoneClaimant 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 DescriptionEmailThis field is for validation purposes and should be left unchanged.