Indemnity Claim Application

INDEMNITY CLAIM APPLICATION

Claimant Name:

Indemnitor Name:

Claim Reference Number (if any):

Date of Loss/Incident:    Location of Loss:

WHEREAS

WHEREAS, Claimant and Indemnitor are parties to an indemnity obligation or agreement governing the allocation of risk between them, evidenced by Agreement Date: (the "Agreement"); and

WHEREAS, Claimant alleges that it has suffered loss, liability, or expense arising from the incident described above for which Claimant seeks indemnification pursuant to the terms and conditions of the Agreement; and

WHEREAS, Indemnitor has agreed to receive and review this Indemnity Claim Application and to process the claim according to the Agreement and applicable law.

SCOPE OF CLAIM / DESCRIPTION OF LOSS

CLAIM AMOUNT AND PAYMENT TERMS

Total Claimed Amount: $

Late Fee / Interest on Overdue Amounts:

Payment will be made by Indemnitor following written acceptance of supporting documentation and verification of the claim. Indemnitor reserves the right to offset amounts paid against any amounts reasonably due from Claimant under the Agreement or by law.

SUPPORTING DOCUMENTATION (CHECK ALL ATTACHED)

Police report or official incident report

Itemized invoices and receipts

Contract or agreement under which indemnity is claimed

Relevant correspondence (letters, emails)

Photographs or physical evidence

Other (describe below)

TERM OF APPLICATION AND TERMINATION

Application Effective Date:    Application Expiration Date:

Notice Period for Withdrawal or Termination by Either Party (days):

This application and the obligations described herein shall survive termination of the Agreement to the extent necessary to permit Indemnitor to investigate, accept, or contest the claim and to satisfy any obligations that have accrued prior to termination.

CONFIDENTIALITY

All information, documentation, and communications exchanged in connection with this application shall be treated as confidential by the parties and used solely for the purpose of evaluating and resolving the claim, except as disclosure is required by law, court order, or as reasonably necessary for the enforcement of rights under this application or the Agreement.

GOVERNING LAW

This Indemnity Claim Application and any dispute arising out of or relating to it shall be governed by and construed in accordance with the laws of the state of: without regard to its conflicts of law principles.

ENTIRE AGREEMENT

This application, together with the Agreement and any written amendments expressly executed by the parties, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior oral or written communications, representations, or agreements. No modification shall be effective unless executed in writing by authorized representatives of both parties.

REPRESENTATIONS AND CERTIFICATION

The Claimant hereby certifies that the information provided in this application and the attachments is true, accurate, and complete to the best of Claimant's knowledge. Claimant authorizes Indemnitor to request and obtain verification, investigation, and documents necessary to evaluate this claim. Claimant understands that knowingly submitting false information may constitute fraud and may give rise to civil or criminal penalties.

ADDITIONAL STATEMENTS

Claimant acknowledges that submission of this application does not constitute acceptance of liability by Indemnitor. Indemnitor reserves all defenses and rights under the Agreement and applicable law. Indemnitor will notify Claimant in writing of the acceptance, denial, or partial acceptance of the claim and of any additional information required to process payment.

Sign Now