File a Claim

TELL US WHAT HAPPENED — WE’LL HANDLE THE REST

To initiate the process of filing a claim or reporting an incident, please complete and submit this form.

Fields marked with * are required to submit a claim.

Once you submit this form, a copy will be sent to your email. Please keep a copy of your entire file along with documents such as a lawsuit, correspondence from a claimant/lawyer and subpoena. The assigned Claims Examiner will ask you for copies.

Policy Number *

Company Name *

Address *

City *

Province *

Main Contact for the Claim *

First Name *

Last Name *

Email *

Phone *

Claimant(s) Name (name of party claiming or potentially claiming against you) *

First Name *

Last Name *

Claimant(s) Company Name *

Claim type *

Date you became aware of the claim or potential claim *

How did you become aware of the claim or potential claim *

Date services were provided *

Please provide details about the selected claim type or any relevant information about errors or potential situations that may result in a claim *

This includes an estimate of potential damages, any lawsuits or correspondence from claimants or lawyers, subpoenas, and impending deadlines. Feel free to provide as much information as possible to help us better understand your claim or potential claim.

THIS REPORT IS MADE IN CONTEMPLATION OF LITIGATION.

Do not admit responsibility, assume any obligation, or make any commitment to money or services without the insurer’s consent, even if you believe there may have been an error, omission, or negligent act on your part. Any such admission, obligation or commitment will vitiate this Policy as far as that particular claim is concerned.