Provide 24/7 Toll-Free Claim Reporting

Transcription

1 Associated Industries Insurance Company Rochdale Insurance Company Technology Insurance Company AmTrust Insurance Company of Kansas Milwaukee Casualty Insurance Company Security National Insurance Company Trinity Lloyds Insurance Company Wesco Insurance Company Provide 24/7 Toll-Free Claim Reporting For ALL States For Florida Workers Comp Only Phone: (866) Florida WC Only: (888) Fax: (775) or (877) Fax: (561) Information Required for All Claims reported. 1. Name of the insured and policy number 2. Date, Time & Place of Accident 3. Description of accident or incident 4. Name, phone and/or of person making the report Additional Information Required for Specific Claim Types A. For Workers Compensation 1. MUST have the injured employee s social security number as it is required by law 2. Description of injury B. For Property Claims 1. Physical address of the loss 2. If more than one building on property must have specific building(s) involved 3. Type of loss, i.e., Fire, Theft, etc. 4. Description of loss or damage C. For Motor Vehicle (Auto) Claims 1. Name, address and contact information of ALL parties involved. 2. Make, model and VIN of the insured vehicle 3. Make, model of all other vehicles involved 4. Current location of all vehicles 5. Name and contact information for each driver and all passengers 6. Name and contact information any known witnesses D. For General Liability Claims 1. Physical address of where the loss occurred 2. Name, address and contact information for all persons claiming injury or damage 3. Name and contact information any known witnesses

2 Third Party Statement Form Location #: Date of Incident: Name: Home Phone: Time of Incident: Address: Business Phone: USE THE BACK OF THIS FORM IF YOU NEED ADDITIONAL SPACE I attest that I am over the age of 21, voluntarily gave this statement and it is true to the best of my ability and knowledge. Signature: Witnessed by: Date: Date:

3 General Liability Kit Checklist General Liability Claim Worksheet General Liability Activity Sheet General Liability Claim Handling Instructions Accident Photograph Sheet Third Party Statement Form Witness Statement Form

4 Witness Accident Statement Witness Information Witness Name: Is witness over 21? Yes: No: Address: City: State: Zip: Home Phone: Cell Phone: Location & activity at time of accident: Description of Accident Describe in detail the accident and how it occurred: Describe in detail conditions that may have contributed to the accident (weather, debris, building conditions, etc.): USE THE BACK OF THIS FORM IF YOU NEED ADDITIONAL SPACE I attest that I am over the age of 21, voluntarily gave this statement and it is true to the best of my ability and knowledge. Signature: Witnessed by: Date: Date:

5 GL Claim Activity Log Claimant Name: Reference #: Date of Incident: Claim #: Date Time Contact/Activity Outcome of Contact/Activity

6 Accident Photograph Sheet Location #: Incident Location: Reference #: Date of Incident: Injured Party: Photo Description: Attach photo Photo Description: Attach photo

7 General Liability Claim Handling Instructions In the event someone is injured at your location report all claims by calling on the date of the incident or at least within 24 hours. Instructions: Initial and date each task as it is completed. Initials Date If the injury is life threatening or serious, call 911. Complete all sections of the General Liability claim form. If possible obtain a statement from the injured party describing the incident and injuries. Obtain statements from involved employees and any witnesses that saw or heard anything. In the event equipment is involved in the incident, forklifts etc., remove from service and have it checked out for defects. Take photographs of the scene but not in front of the injured party. Attach photographs to photograph sheet. Do not take photographs of the injured party. Check to see if any security cameras captured the incident. If so preserve the images. Secure all documentation until contacted by the adjuster.

8 GENERAL LIABILITY CLAIM WORKSHEET Instructions: Use this form to summarize injured party's accident information before calling the toll free claim reporting number. Claims must be reported as quickly as possible after the accident occurrence. The reporting number is. Reported by Caller s Name (First/Last) Caller Phone Caller Title Date Called In Date of Accident Time of Accident Date injury reported Incident only? When Yes No Describe what happened Physical conditions that may have contributed to the accident Accident Description Type of injury/body part, if known Subrogation Potential: Accident occurred on premises? Location Yes No Was incident captured on video? Yes No Witness #1 Name Location where incident occurred SSN Address Employee? Employee Shift Yes No City Work Phone State/Zip Home Phone Injured Party Claimant s First Name Middle Last If claimant is a minor, list parent or guardian name Address City State Zip Home Phone Age Sex SSN Work Phone Occupation Injuries Describe visible injury Was the claimant transported by ambulance? Yes No Physician Name Phone Address City State Zip Hospital Name Phone Address City State Zip Property Damage Describe damaged property (be specific) If vehicle/equipment involved, year/make/model Estimated amount of damage Photos taken By whom $ Yes No Investigated by