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Incident Report
Incident Report
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*
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Email
This field is for validation purposes and should be left unchanged.
First Notice of Loss
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
*
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
Injured People
Workers Compensation: Injured Employee Demographic Information
Date of Birth
*
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
Remarks
Attachments/Files
Upload any photos/files/attachments related to the incident
Drop files here or
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Accepted file types: jpg, jpeg, png, pdf, Max. file size: 256 MB.
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