THIS
CLAIM IS:
An
Actual Claim whereas you have received a bill, suit, call, or
formal notice seeking collection for damages
for
Reporting Purposes Only, whereas it could develop into the above |
| WHO
IS TO BE LEAD CONTACT FOR FURTHER INVESTIGATION OR CLAIM
INFORMATION SAME
AS ABOVE OR COMPLETE |
| Lead
Contact Name:
Phone #:
Email: |
| CLAIM
INFORMATION |
| Date
of Claim Occurrence:
Time of Claim Occurrence:
AM
PM |
| Location
of the Claim (address or specific area): |
Description
of what happened?
|
If an
authority such as police, fire, medical was contacted, please
name:
What is the report # of the authority, if known: |
| INJURED
PERSON OR INFORMATION FOR OWNER OF DAMAGED PROPERTY |
| Is
this a notice of an INJURY
/ FATALITY and/or PROPERTY
DAMAGED |
| Named
of injured person or name of owner of damaged property: |
| Address
of above (incl. City, State, Zip if known): |
| Sex: Male
Female
Age (approx. if not known):
Phone #: |
| Occupation
of Injured Party or owner of damaged property:
or Not
Known |
| Description
of Injury or Damaged Property:
or Fatality |
| If
damaged property, where can property be seen:
or Unknown
Call
Owner |
| AMOUNT
OF DAMAGES |
| Estimate
Amount of Damages ($ Amount):
or Unknown |
| WITNESSES |
|
No
Witnesses Numerous
Witnesses (Listing of individuals is redundant) |
| Schedule
of Individual Witnesses if neither check off box above is
appropriate |
| 1.
Name:
Address:
Phone: |
| 2.
Name:
Address:
Phone: |
| 3.
Name:
Address:
Phone: |
| ADDITIONAL
NOTES / COMMENTS |
|
|