D&O Claims Notification Form

Important information

 Do not make any admissions of liability without seeking prior written approval.
 Provide all details of the matter you are seeking to notify as fully and accurately as possible.
 Please note that, following our review of the information you provide, we may request further information and that
this form should not be regarded as a waiver of the Insurer’s right to request such further information or of any
other right under the Policy or at law that may be deemed to apply.

Policyholder: Policy number:

Policy period: Loss location:

1. Description

Please describe below the Claim, circumstance(s) which may give rise to a Claim, Investigation or other matter you are
seeking to notify. Your description should include (but need not be limited to) details of:
 for any Claim you are seeking to notify, the (third party) claimant, allegations made and any monetary
compensation or other remedy the claimant is seeking;
 for any circumstance(s) you are seeking to notify, why you consider it/they may give rise to a Claim; and,
 for any Investigation you are seeking to notify, the formal request for information or attendance at an interview
and the body that has made this request
(please continue the description on a separate page as an attachment to this form if necessary)

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 2. Date of first awareness
Please specify the date on which you first became aware of the matter you are seeking to notify.

3. Details of individual(s)

Please provide the details indicated below, as applicable, of any natural person* or legal person**: (i) against whom any
Claim you refer to in section 1 of this form may be or has been made; or (ii) the subject of any formal request you refer
to in section 1 of this form (please continue your response on a separate page as an attachment to this form if
necessary).

Name of natural or legal Employer and its Position held Period during which Does the Employer or
person relation to the position held Policyholder plan to
Policyholder (e.g. indemnify the
subsidiary) individual? (Y/N)

*A human being ** A company or partnership

4. External legal representation or other professional adviser

If, in relation to the matter you are seeking to notify, you anticipate incurring any Defence Costs and Expenses, please
provide the details indicated below of any law firm or other external professional adviser you propose to retain (subject
to the prior written consent of your Insurer).

Firm Name of contact at the firm Hourly charge-out rate or alternative fee
arrangement proposed

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 5. Documents

Please enclose with this form any documents that you consider provide additional support for your responses set out in
the preceding sections of this form. Such documents may include (but need not be limited to) any:
 written demand or written allegation;
 pleadings issued or served in relation to any relevant civil or arbitral proceedings;
 formal requests for information or attendance at an interview;
 contract of employment for any natural person you refer to in section 3 of this form; or
 draft terms and conditions, retainer or engagement letter for any law firm or other external professional adviser
you refer to in section 4 of this form.
Please list below the documents you have attached to this form in response to the request set out above (please
continue the list on a separate page as an attachment to this form if necessary):

1.

2.

3.

Completed by: Date:

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