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Claim Notice Report

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Please complete this form as fully as possible.

DO NOT delay filing this report because you are waiting on additional information.

Please immediately e-mail, fax or courier to LAWPRO^® copies of all relevant documentation including, if applicable, the Statement of Claim and other pleadings.

We will be unable to commence our investigation or consider the appointment of counsel until we receive this documentation. You should take any necessary steps to protect your interests and those, if any, of LAWPRO with respect to any deadline in the interim.

* mandatory field

I am reporting a claim *
against me on behalf of another lawyer

FILER INFORMATION

    I am*
     Current or former partner of the Insured LAWYER
     Current or former employer of the Insured LAWYER
     Employee of the Insured LAWYER
     Claims Administrator at the Insured LAWYER's current or former firm
     Executor/Administrator of the Insured Lawyer's Estate
     Other, please specify:

Your LSUC Number (if applicable):

Your Last Name:*

Your First and Middle Name(s):*

Telephone Number:*
- - ext.

E-mail: A confirmation e-mail will be sent to this address

    Country:

    If other, please specify:

     Mailing Address:

City:

Firm Name (if applicable):

INSURED INFORMATION

Insured LAWYER Last Name: *

Insured LAWYER First and Middle Name(s): *

- - ext.

E-mail: A confirmation e-mail will be sent to this address

     Country: *

     If other, please specify:

     Mailing Address: *

City: *

Firm Name on date of alleged error: *

CLIENT/CLAIMANT INFORMATION

2. Claimant Last or Corporate Name: *

Claimant First Name:

CLAIM INFORMATION

3. Date on which the alleged error or omission occurred: *

4. Date on which you first became aware of (potential) claim: *

5. How did you become aware of the claim: *

6. Has a proceeding been commenced against you? *

Yes No

7. Does your firm carry excess insurance? *

Yes No Don't know

8. Area of Practice:

DESCRIPTION OF CLAIM

9. Describe fully the circumstances giving rise to the claim. To the extent known, include relevant dates: *
      We recommend you save the content using Notepad or Microsoft Word as a text file in your computer first,
      and then copy the content and paste into the text area below.

      Note: You will have the opportunity of uploading documents in Question 10.

10. Attach relevant documents: *

Yes No

11. If there are any documents you have not attached above, please indicate below the method in which you plan to send them: *
e-mail fax same-day courier overnight courier All relevant documents attached
No relevant documents to provide

Next steps:

Note that you must first 'Review' your Claim Report form before being able to SUBMIT it online.
Click 'Review' to see a summary of your entries before submitting your Claim Report form; OR
Click 'Reset' to abandon your entries and start over; OR
Click 'Cancel' to exit the Claim Report form.

*E-mail:*	*New.Claims.Co-ordinator@LAWPRO.ca*
*Fax:*	*1-800-286-7639 Attn.: Claims Coordinator*

*Courier:*	Attn: Claims Coordinator LAWPRO 250 Yonge Street, Suite 3101 P.O. Box 3 Toronto, ON M5B 2L7

July 31, 2010
Real estate and civil litigation transaction levies and forms are due for the quarter ended June 30, 2010.

Transaction filing
• online forms
• pdf forms

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