Incident notification form

If you are unsure if the incident that has occurred requires a claim, fill the form below and one of our team will evaluate it, and decide if it requires a new claim to be raised.
If you need to raise a claim please follow the New Claim path.

Section 1 - Reporter details (You as the reporter)

 

Are you a member of:

 

 

IMPORTANT

If you are a member of Australian Dental Association (ADA), please contact your association directly to report an incident or claim.

 

 

 

 

 

 

 

 

 

IMPORTANT

If you are a pharmacist, your Guild Insurance policy includes membership of Pharmaceutical Defence Limited (PDL). Please contact PDL directly to report an incident or claim and to receive peer support and counselling from one of PDL’s Professional Officers. 

You can phone PDL on 1300 854 838 or log into the member portal at www.pdl.org.au to access PDL’s Incident Reporting System

 

 

 

 

 

 

 

Are you reporting on behalf of someone else?*
Is this a notification only, or do you require a call to back to discuss further?

Section 2 - Policy information

 

Section 3 - Event details

 

Was a person involved?*
Was there anyone else involved?*

Section 3.5 - The event

Section 4 - Post event details

Has communication been received from a regulatory or disciplinary body?*
Add another
Has a demand been received for compensation, either verbally or in writing (including legal proceedings)?*
Add another
Have you admitted responsibility?*

Why do you believe this? Is anyone else responsible? Please provide these details.

Add another

Section 5 - Insurance information

Are there any other insurance policies which may provide cover in respect of this incident?*

Section 6 - Information regarding GST

 

Are you registered for GST?*
Have you claimed an input tax credit for the GST included in your insurance policy premium?
If yes, was the amount of GST claimed less than 100% of the GST included in the premium?

Complete the code below before submitting