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Disputes Tribunal
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What is this form for? Use this form if you (the applicant) have been, are entitled to be, or have sought to be, indemnified
(that is, compensated) by your insurer for any loss caused by or arising out of the act, omission, or
event on which your Disputes Tribunal claim is based, and your insurer wishes to waive notice of
proceedings, or to abandon rights of subrogation, or both, in respect of your Disputes Tribunal claim.
Completing and 1. This form is to be filled in by you (you must fill in Part 1) and your insurer (it must fill in Parts 2
submitting this form and 4).
2. Please fill in CAPITAL LETTERS.
3. Check, before submitting this form, that it is complete and that you and your insurer have signed
and dated it.
4. Submit this form with your Disputes Tribunal Claim Form.
5. Submit this form by post or in person to your closest District Court.
Form 4: Acknowledgement from Applicant’s Insurer
Subrogation Subrogation is an insurer taking the place of an insured person, and having the benefit of the insured person’s rights,
in respect of the insured person’s claim against a third person.
Part 1: Parties and insurers
Applicant’s name (individual or organisation):
Attention (organisation’s contact):
First respondent’s name (individual or organisation):
Attention (organisation’s contact):
Name of second respondent (if any, individual or organisation):
Attention (organisation’s contact):
Applicant’s insurer’s full legal name:
Attention (insurer’s contact):
Part 2: Waiver of notice
Does the applicant’s insurer require notice? (please tick one) Yes No
(Office use only)
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Part 3: Subrogation
Select and complete the options that apply:
There are no uninsured losses
There are uninsured losses of the following amount, namely: $
The insured losses are the following amount, namely: $
I, the insurer, Either
(a) abandon subrogation rights in respect of: $
and wish to exercise subrogation rights in respect of the balance of the insured losses
of: $
(b) abandon all subrogation rights
Part 4: Applicant’s insurers details
Insurance claim number:
Applicants insurer’s full legal name:
Attention (insurer’s contact):
Contact details
Daytime telephone number: ( )
Mobile telephone number: ( )
Fax number: ( )
Email address:
Insurer’s signature: Date / / (day / month / year)
Applicant’s signature: Date / / (day / month / year)
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