CLAIM REPORTING GUIDE

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1 CLAIM REPORTING GUIDE Our goal at J. L. Hubbard Insurance & Bonds is to provide you with the most effective and superior claim service possible. We have designed this claim kit to serve as a simple guide to assist you with prompt and accurate reporting of Automobile, Property, General Liability, and Workers Compensation claims. We pledge to work diligently and to the best of our ability to ensure your claims are processed promptly and fairly. These instructions may not cover every possible situation. If you have any questions or would like assistance, please call our office. J L HUBBARD INSURANCE & BONDS CLAIM DEPARTMENT 1090 South Route 51 PO Box 14 Forsyth, IL Phone: Fax:

2 AUTOMOBILE CLAIM REPORTING GUIDE PROMPTLY report any Automobile claim to J L HUBBARD INSURANCE & BONDS with as much detail as possible using the enclosed Automobile Accident Information Form. Do not delay reporting a claim because you are lacking some of the information. ASSUME NO LIABILITY - MAKE NO PAYMENTS without your insurance company s consent. Unauthorized payments may not be reimbursed and may void the protection of your automobile insurance. COOPERATE WITH YOUR INSURANCE COMPANY ADJUSTER in the investigation, settlement and/or defense of the claim. IMMEDIATELY forward any demand notice, summons or other legal paperwork received concerning any alleged accident to our office. REPORT TO LOCAL POLICE DEPARTMENT any automobile accident while at the scene of the accident. Also report any total theft of a vehicle. PROTECT THE PROPERTY from further damage by reasonable means. FORWARD THE COMPLETED MOTOR VEHICLE ACCIDENT REPORT that you received from the reporting officer to the appropriate state office. The address will appear on the report. Please report ALL automobile accidents to our office. If the other driver is at fault and their insurance will be handling the loss, we may be able to assist you should problems arise in the handling of the claim.

3 AUTOMOBILE LOSS INFORMATION FORM A UTOMOBILE ACCIDENT Today s Date D ate of Loss Time AM/PM Insured Policy Number In sured Name In sured Address Insured Driver/Address Injured? Insured Phone Numbers: Home Work Cell Insured Vehicle Vehicle Drivable? Yes No If Not Drivable Location of Insured Vehicle L ocation of Loss Police Department Report Number Other Driver/Address Injured? Other Vehicle Vehicle Drivable? Yes No Other Owner/Address Injured? Other Driver Phone Numbers: Home Work Cell If Not Drivable Location of Other Vehicle O ther Vehicle Owner/Address Other Insurance Company Policy Number P assenger Names O ther Injured Parties Description of Loss Other Notes

4 GENERAL LIABILITY CLAIM REPORTING GUIDE PROMPTLY report to our office any occurrence that may result in a claim using the enclosed General Liability Loss Information Form. ASSUME consent. NO LIABILITY MAKE NO PAYMENTS without your insurance company s IMMEDIATELY forward any demand notice, summons or other legal paperwork received concerning the claim. COOPERATE WITH YOUR INSURANCE COMPANY ADJUSTER in the investigation, settlement and/or defense of the claim or suit.

5 GENERAL LIABILITY LOSS INFORMATION FORM G ENERAL LIABILITY LOSS Today s Date D ate of Loss Time AM/PM Insured Policy Number In sured Name In sured Address Insured Phone Numbers: Home Work Cell L ocation of Loss Police/Fire Department Report Number O ther Party Involved O ther Party Address Other Party Phone Numbers: Home Work Cell Other Insurance Company Policy Number Injured Parties? Yes No Any Fatalities? Yes N o List Names of Injured/Fatalities Below Names of Injured N ature of Injury Address/Phone of Injured Other Party Property Damaged? Yes No Type of Property Location of Damaged Property Description of Loss Other Notes

6 WORKER S COMPENSATION CLAIM REPORTING GUIDE Submit an Illinois Worker s Compensation First Report of Injury form or Form 45 IMMEDIATELY after you have received notice of any injury or occupational illness from an employee. It is the EMPLOYER S RESPONSIBILITY to submit a First Report of Injury to J L HUBBARD INSURANCE & BONDS and also to the ILLINOIS INDUSTRIAL COMMISSION. (There is a sheet of labels included for this purpose.) DO NOT WAIT FOR MEDICAL BILLS. ALL DEATH CLAIMS SHOULD BE REPORTED IMMEDIATELY. Please fill out the Form 45 as completely as possible. Most of the information requested on the form is absolutely necessary for the claim to be processed and without the information; the claim cannot be set up for handling. If you ever need assistance, please call our office. Advise all medical care providers to forward their bills to you, the employer. The bills should include your company name as well as the employees. It is imperative that you forward each and every bill that you receive to our office or directly to the adjuster assigned to the claim. The providers do not automatically bill directly to the insurance company. Encourage all employees to immediately give notification of an injury or illness occurring as a result of their job duties. It is suggested that the injured employee give you written notice of the incident whenever possible.

7 ILLINOIS FORM 45: EMPLOYER'S FIRST REPORT OF INJURY Please type or print. Employer's FEIN Date of report Case or File # Is this a lost workday case? Employer's name Doing business as Yes / No Employer's mailing address Nature of business or service SIC code Name of workers' compensation carrier/admin. Policy/Contract # Self-insured? Employee's full name Social Security # Birthdate Yes / No Employee's mailing address Employee's address # Dependents Employee's average weekly wage Male / Female Married / Single Job title or occupation Date hired Time employee began work AM PM Date and time of accident If the employee died as a result of the accident, give the date of death. Address of accident Last day employee worked Did the accident occur on the employer's premises? Yes / No What was the employee doing when the accident occurred? How did the accident occur? What was the injury or illness? List the part of body affected and explain how it was affected. What object or substance, if any, directly harmed the employee? Name and address of physician/health care professional If treatment was given away from the worksite, list the name and address of the place it was given. Was the employee treated in an emergency room? Was the employee hospitalized overnight as an inpatient? Yes / No Yes / No Report prepared by Signature Title and telephone # Please send this form to the ILLINOIS WORKERS' COMPENSATION COMMISSION 4500 S. SIXTH ST. FRONTAGE RD. SPRINGFIELD, IL IC45 11/11 By law, employers must keep accurate records of all work-related injuries and illness (except for certain minor injuries). Employers shall report to the Commission all injuries resulting in the loss of more than three scheduled workdays. Filing this form does not affect liability under the Workers' Compensation Act and is not incriminatory in any sense. This information is confidential

8 PROPERTY CLAIM REPORTING GUIDE PROMPTLY report to J L HUBBARD INSURANCE & BONDS any loss or damage to property using the enclosed Property Loss Information Form. NOTIFY police if there has been a break-in, burglary or vandalism. PROTECT the property from further damage using reasonable means. Set the damaged property aside (if applicable) for examination by your adjuster. Do not destroy or dispose of property prior to examination. Keep a record of your expenses for emergency and temporary repairs for consideration in the settlement of the claim. Prepare an inventory of damaged or stolen property including quantities, costs, values and amount of loss claimed. COOPERATE WITH YOUR INSURANCE COMPANY ADJUSTER in the investigation or settlement of the claim. TAKE PHOTOS OF DAMAGE AS SOON AS DISCOVERED WHENEVER REASONABLY POSSIBLE.

9 PROPERTY LOSS INFORMATION FORM Today s Date PROPERTY LOSS Date of Loss Time AM/PM Insured Policy Number Insured Name Insured Address Insured Phone Numbers: Home Work Cell Location of Loss Type of Property Involved Description of Loss Police Notified? Yes or No Name of Police/Fire Department Police/Fire Report Number Other Notes

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