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Notification of Claim

Circumstances

I confirm that I have read and understood the "Claims Made Policy" and "Your Duty of Disclosure” sections prior to making this declaration. I also further declare that the statements and information provided are true and correct, that I have not suppressed or mis-stated any facts and that should any information given by me alter between the date of the proposal and the inception date of the insurance to which this proposal relates, I will give immediate notice thereof.

YOU HAVE DECLARED THAT YOU HAVE RECEIVED NOTIFICATION OF A CLAIM BUT YOU HAVE NOT INFORMED INSURERS.

YOU HAVE DECLARED THAT CIRCUMSTANCES EXIST WHICH YOU BELIEVE MAY RESULT IN A CLAIM AGAINST YOU OR YOUR EMPLOYEES BUT YOU HAVE NOT INFORMED INSURERS.

IN ORDER TO PROCEED, PLEASE CONTACT:

Mr. Martin Giggins
Willis Hong Kong Limited
17/F, Lee Garden Three,
1 Sunning Road,
Causeway Bay, Hong Kong

Tel: + 852 2195 5633
Email: martin.giggins@willistowerswatson.com