CLAIM DETAILS
INSURED
PLAINTIFF / OTHER
QCA IS INSTRUCTED TO
Please select
Settle Costs
Recover Costs
OTHER PARTIES CONTRIBUTING TO COSTS?
No
Yes
INSURER CONTRIBUTION:
ADDITIONAL COMMENTS
OTHER PARTY SOLICITOR'S DETAILS
COMPANY OR FIRM
FILE REFERENCE
TEL.
(Inc. area code)
PL COSTS IN
No
Yes
VALUE COSTS
$
(if known)
INSURER CONTACT DETAILS
CLAIMS CONTACT PERSON
TEL.
(Inc. area code)
INSURANCE COMPANY
Please Select
AAMI
Allianz
AMP
APIA
Avant
Calliden
CGU Sydney
CGU Melbourne
Claims Services Australia
GIO
Guild
Lumley
QBE
Suncorp
TMF
Vero
Zurich
Other: Describe at 'Additional Coments'
TYPE OF CLAIM
Please Select
Construction & Engineering
CTP
Global & Risk Managed
Home Warranty
Marine
Personal Injury
Professional Indemnity
Product Liability
Property
Public Liability
Workers Compensation
Motor
Other: Describe at 'Additional Coments'
PREFERRED EMAIL
FILE REFERENCE
INSURER SOLICITOR'S CONTACT DETAILS
SOLICITOR'S FULL NAME
COMPANY / FIRM
TEL.
(Inc. area code)
FILE REFERENCE
EMAIL
This instruction will be emailed to the Insurer and Panel Solicitors