LEXi – Claim Submission You must answer all questions honestly and fully. The completion of this claim form is not an admission of indemnity by your Insurer. Please complete all sections below and press "Submit to ProClaim". A record of the answers will be automatically emailed to you, your broker, and ourselves. 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 YOUR BROKERInsurance Broker Company *Contract Person (Broker) *Mobile Phone Number (Broker) *Mobile preferred. If Landline, please include area codeEmail Address (Broker) *Would you prefer for ProClaim to deal direct with your broker? *YesNoDETAILS 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 *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 fileDECLARATIONI, the under-named, hereby declare that: *If any personal information is provided, it is understood that this information will be collected, held, used and disclosed by Insurer(s) and their service providers in order to issue, administer and manage products and provide services, including claims investigation and administration, and for data analytics;All answers and statements made in this claim form are true, correct and complete in every respect;Where any part(s) of this claim form has been completed by others, I have checked their answers and confirm they are true, correct and complete in every respect;I am authorised to act for and on behalf of all persons who may be entitled to indemnity under our Legal Expenses Policy;Authorisation is given to obtain, from any other party, information that is, in the Insurer(s) or its service providers view, relevant to this claim.My Full name (the person completing this form) *My Position / Title *My Mobile Phone Number *Mobile preferred. If Landline, please include area codeMy Email Address *Submit to ProClaim (with copy to me, our broker and Edge Underwriting)
