ERROR & OMISSION

1.1 Current date *

1.2 Name of person filling out this form *

1.3 Relationship to the Insured

1.4 Telephone number *

1.5 Fax number or cell phone

1.6 Email addres *

2. Information

2.1 First name and last name of the member *

2.2 OIQ member number *

2.3 Name of company; firm; enterprise; organization

2.4. Mailing address of the member *

City:

Province: *

Postal code: *

2.5 Telephone number of the member *

2.6 Cellular - Other telephone number of the member

2.7 Email addres *

2.8 Policy number for general practice

2.9 Policy type *

2.10 Name of brokerage

3. General Claim Information

3.1 Please describe the facts; the alleged injury or damage; the detail leading you to believe that a claim will arise from the circumstances or verbal threats:

3.2 Date of the alleged error or omission *

3.3 Date on which you learned of the existence of the error or omission, or of the circumstances which could give rise to a claim: *

3.4 Please describe how you learned about the existence of the claim or the circumstances that could give rise to a claim:

3.5 Time (report)

3.6 Estimated value of loss

3.7 Other parties involved

3.8 Location of loss or project

City:

Province:

Postal code:

4. Claimant Information

4.1 Name of claimant *

4.2 Address (if known)

City:

Province: *

Postal code: *

4.3 Have you been served with a Writ of Summons, Statement of Claim or Introductory Motion, Intervention Act or other? * Yes No

5. Additional Information

5.1 Provide any additional information you have for this claim and any explanations you deem relevant to provide:

Please check the appropriate box below to send the supporting documents associated with this claim. Be sure to include a copy of any other legal documents, if applicable. Please specify if the documents relate to a claim already submitted through our website.

To forward any supporting electronic documents to this E-notice of Claim: *

Send attached documents to this form :

Send separately via email : reclamation.ca@victorinsurance.com

Send separately via fax : 613-786-2001

Send separately via courier or mail : Victor Canada
500 - 1400 Blair Place
Ottawa ON K1J 9B8

I do not have supporting electronic documents to submit.

You will receive a confirmation email upon submission of the above form, and a claims analyst will contact you within two business days to discuss this notice. If you have not received a response from our Claims department within two business days, or if you have a question or comment, please contact our office immediately to speak to one of our claims analysts at 1-800-267-6684. Our regular business hours are 8:00 a.m. to 5:00 p.m. EST, Monday to Friday.

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