Claims Submission Form

HUB Brokerage Name:

HUB Brokerage Address:

HUB Brokerage Phone Number:

Email Address:

Client/Claimant Name:

Client/Claimant Address:

Briefly set out the nature of the claim:

Date you first became aware of the potential claim:

How did you become aware of the potential claim:

Letter from client/claimant
Statement of claim
Oral complaint from client/claimant
Letter from lawyer
Other

If "Statement of claim" is checked above, when was it received?:

If "Other" is checked above, provide details.