LEXi – Claim Submission Please complete all sections below and press "Submit to ProClaim". A copy of the form will be automatically emailed to you. INSURED'S DETAILSName of Insured (Business/Company) *This is the policy holder. eg. ABC Pty LtdPolicy Number *eg. LEXI0000000 / 10Insured's Contact Person *Mobile Phone Number *Mobile preferred. If Landline, please include area codeEmail Address *DETAILS OF THE PARTY YOU ARE IN DISPUTE WITHName of Business/Company *Contact Person *Mobile Phone Number *Mobile preferred. If Landline, please include area codeEmail Address *Would you prefer for ProClaim to deal direct with your broker? *YesNoInsurance Broker Company *Contract Person (Broker) *Mobile Phone Number (Broker) *Mobile preferred. If Landline, please include area codeEmail Address (Broker) *DETAILS OF THE DISPUTE / CONFLICT / LEGAL ACTIONHave you already made use of the free, initial legal advice line regarding the matter? *YesNoOn what date did you first become aware of this matter? *On what date do you believe it became a dispute? *Provide full details of the conflict / dispute / legal action *$ Amount in Dispute *Likely legal cost to defend / pursue *Enter $0 if unknownCOVER SECTIONUnder what section(s) of the policy are you claiming? 1. Privacy 2. Prosecution Defence 3. Employee Protections 4. Property Protection 5.Tenancy Dispute 6. Statutory Licence 7. Injury Protection 8. Tax Dispute / Investigation 9. Personal Injury 10. Discrimination Protection 11. Contract Dispute with Customer/Supplier UnknownOptional Extensions (only available if showing as covered under your Policy Schedule 1. Construction Contract Dispute 2. Employment Contract Dispute 3. Personal Cover For EmployeesPLEASE ATTACH ANY SUPPORTING DOUMEMENTS / CONTRACTS / PICTURESUpload 1Choose FileNo file chosenDelete uploaded fileUpload 2Choose FileNo file chosenDelete uploaded fileUpload 3Choose FileNo file chosenDelete uploaded fileUpload 4Choose FileNo file chosenDelete uploaded fileUpload 5Choose FileNo file chosenDelete uploaded fileUpload 6Choose FileNo file chosenDelete uploaded fileSubmit to ProClaim
