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Incident Report
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What​ ​did​ ​this​ ​incident​ ​involve?​
*
Person
Property
Auto
What​ ​kind​ ​of​ ​claim​ ​are​ ​you​ ​reporting?
*
General Liability examples include: Third Party Property Damage, Slips & Falls, Products Liability, Completed Operations, Customer, (Bodily) Injury, Personal Injury
Property Loss examples include: Damage to your Property and may include the structure, contents and business interruption
Auto Liability Physical Damage examples include: Automobile accidents relating to the physical damage to your owned or leased vehicles and damages of 3rd parties for Bodily Injury or Property Damage
Workers Compensation examples include: Injuries sustained by an employee in the workplace while in course and scope of employment
Miscellaneous examples include: Claims made against Directors and/or Officers of your company, Errors and Omissions, Professional Liability, Employee Practices Liability and Cyber Liability
What​ ​was​ ​the​ ​nature​ ​of​ ​the​ ​incident?
*
Personal injury and/or property damage
An incident that resulted in one or more personal injuries
Near miss
A close call where no property was damaged and no personal injury sustained, but either could easily have occurred
Reporter First Name
*
Reporter Last Name
*
Reporter Phone Number
*
Reporter Email
*
Insured Information
Company​ ​Name​ ​(Insured)​
*
Address
*
Street
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Business​ ​Phone​ ​Number
*
Insured Email
*
Insured​ ​Location​ ​Code​
If Applicable
Occurrence/Loss Information
Date​ ​and​ ​Time​ ​of​ ​Loss
*
MM slash DD slash YYYY
Time
Hours
:
Minutes
Exact​ ​time​ ​unknown​
Yes
No
City​ ​of​ ​Loss​
*
State​ ​of​ ​Loss​
*
State​ ​of​ ​Loss
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Claimant​ ​First​ ​Name
*
Claimant​ ​Last​ ​Name
*
Description​ ​of​ ​occurrence​ ​or​ ​loss​ ​and​ ​damage​ ​(be​ ​specific)​
*
​Location​ ​of​ ​Occurrence/Loss​
*
​Loss​ ​Address​
if applicable
Police​ ​or​ ​Fire​ ​Department​ ​Which​ ​Reported​
Kind​ ​of​ ​Loss​
*
Fire
Flood
Theft
Hail
Wind
Other
Probable​ ​$$​ ​amount​ ​of​ ​entire​ ​loss​
Insured Vehicle Information
Make
Model
Model Year
VIN
*
License​ ​Plate​
Driver​ ​First​ ​Name​
Driver​ ​Last​ ​Name​
Driver​ ​Address​
Street Address
City
State / Province / Region
ZIP / Postal Code
​Police​ ​Department​ ​Notified​
Description​ ​of​ ​Damage​ ​to​ ​Vehicle​
*
Body Shop Information
​Body​ ​Shop​ ​Name
Third Party Address​
Street Address
City
State / Province / Region
ZIP / Postal Code
Phone​ ​Number​
Third Party Vehicle Information
Make
Model
Model Year
VIN
​License​ ​Plate​
Driver​ ​First​ ​Name​
Driver​ ​Last​ ​Name​
Driver​ ​Address​
Street Address
City
State / Province / Region
ZIP / Postal Code
Description​ ​of​ ​Damage​ ​to​ ​Vehicle​
Injured Person(s)
Who​ ​was​ ​injured?​
Injured Name
Injured First Name
Injured Last Name
Injured Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Injured Phone Number
Injured ​VIN​
*
License​ ​Plate​ ​#​
Nature​ ​of​ ​Injuries​
Workers Compensation: Injured Employee Demographic Information
Date of Birth
*
MM slash DD slash YYYY
SSN
*
Phone Number
*
Email
Type of liability
You are the
*
Owner
Tenant
Manufacturer
Vendor
Auto
Other
Type​ ​of​ ​premise/product​ ​(business,​ ​residential​ ​property,​ ​etc.)
*
Owners Name
First
Last
Owners Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Owners Phone Number
Type of liability
You are the
*
Owner
Tenant
Manufacturer
Vendor
Auto
Other
Type of claim
*
Directors and Officers
Errors & Omissions
Profesional Liability
Ciber Liability
Other
Unknow
Employment Practices & Liability
Owners Name
First
Last
Owners Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Owners Phone Number
Witness Information
Who​ ​were​ ​witnesses?
First Name
Last Name
Phone Number
​Remarks​
Attachments/Files
Upload​ ​any​ ​photos/files/attachments​ ​related​ ​to​ ​the​ ​incident​
Drop files here or
Select files
Accepted file types: jpg, jpeg, png, pdf, Max. file size: 256 MB.
Send​ ​a​ ​confirmation​ ​to​ ​the​ ​following​ ​email​ ​address​