CLAIM REPORTING GUIDE
|
|
- Phoebe Fletcher
- 8 years ago
- Views:
Transcription
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: mbewing@jlhubbard.com
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
19. Injury, Accident, and Loss Reporting
19. Injury, Accident, and Loss Reporting Overview This section discusses the following topics: Where to Report Claims Reporting Workers Compensation Illnesses and Injuries Reporting Automobile Accidents
More informationSUSQUEHANNA CONFERENCE OF THE UNITED METHODIST CHURCH WORKERS COMPENSATION
SUSQUEHANNA CONFERENCE OF THE UNITED METHODIST CHURCH WORKERS COMPENSATION I. Workers Compensation Coverage II. Who Is Covered III. Who Is T Covered IV. How to Report a Claim I. WORKERS COMPENSATION COVERAGE
More informationACCIDENT, INJURY, AND INCIDENT REPORTING PROCEDURES
ACCIDENT, INJURY, AND INCIDENT REPORTING PROCEDURES VEHICLE ACCIDENTS/PROPERTY DAMAGE Non-Workers Compensation Accident Report Form Attached is a sample copy of the accident report for vehicle damage,
More informationDate of Birth: / / Male Female Martial Status: Language: English Spanish Other: E-mail: Occupation: Date Hired: / /
Early reporting can save you money. Report all injuries immediately! The information below allows Pinnacol Assurance s customer service representatives to quickly and accurately process your claim. Use
More informationInjury Reporting PACKET. 1-888-627-7586 www.careworksmco.com
Injury Reporting PACKET 1-888-627-7586 www.careworksmco.com Workplace Injury. Take the Right Steps. Helping Simplify the First Report of Injury (FROI) Process 1 2 3 4 INJURED EMPLOYEE 4-STEP PROCESS Immediately
More informationWe thank you for your business, and look forward to providing you with the necessary protection and care for your business and employees.
RE: Workers Compensation Claims Kit Welcome to the Workers Compensation Insurance Program offered through Tower Group Companies. While we hope that your company never has to experience a workers compensation
More informationWorkers Compensation Claim Form (DWC 1) & Notice of Potential Eligibility e3301 (rev. 01/12) DWC 1 (rev. 6/10)
Workers' Compensation Claim Kit Instructions for Completing the Forms Required to Report a Work-Related Injury or Illness California Department of Human Resources Workers Compensation Program What are
More informationOSHA & Workers Compensation Requirements Recording Workplace Injuries & Illness
Human Resources 30-71 7/15/91 3/25/02 1 of 7 OSHA & Workers Compensation Requirements Recording Workplace Injuries & Illness VPSI, Inc. is subject to the record-keeping requirements of the Occupational
More informationSuperintendent s Circular
Superintendent s Circular School Year 2011-2012 NUMBER: HRS-PP7 DATE: WORKERS COMPENSATION PROCEDURES OBJECTIVE The Boston Public Schools Workers Compensation Service is located within Boston City Hall,
More informationYour Accident Fact Kit
Your Accident Fact Kit We hope you find our Accident Fact Kit helpful in the event of an accident. Please be sure to print multiple copies and keep them in the glove compartment of your vehicle in the
More informationRUTGERS POLICY. Errors or Changes? Contact: Department of Risk Management and Insurance, 848-932-3005
RUTGERS POLICY Section: 40.3.1 Section Title: Risk Management & Insurance Policy Name: Risk Management and Insurance Policies Formerly Book: 5.3.1 Approval Authority: Senior Vice President for Finance
More informationWORKERS' COMPENSATION CLAIMANT INFORMATION PACKET
WORKERS' COMPENSATION CLAIMANT INFORMATION PACKET Instructions Statement of Rights Prescription ID and Pharmacy Information The New York State Insurance Fund TLC EMERGENCY MEDICAL SERVICES Inc. TLC MEDICAL
More informationMOTOR VEHICLE CLAIM FORM
MOTOR VEHICLE CLAIM FORM Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring the enclosed claim form
More informationYour Accident Fact Kit
Your Accident Fact Kit We hope you find our Accident Fact Kit helpful in the event of an accident. Please be sure to print multiple copies and keep them in the glove compartment of your vehicle in the
More informationTHE SALAZAR LAW FIRM, P.A. NEW CLIENT INFORMATION SHEET (PERSONAL INJURY MOTOR VEHICLE) PERSONAL INFORMATION:
THE SALAZAR LAW FIRM, P.A. NEW CLIENT INFORMATION SHEET (PERSONAL INJURY MOTOR VEHICLE) TODAY'S DATE PERSONAL INFORMATION: DATE OF ACCIDENT NAME HOME ADDRESS CITY STATE ZIP HOME TELEPHONE ( ) DATE OF BIRTH
More informationGeorge Mason University Accident and Incident Plan
George Mason University Prepared by: Environmental Health and Safety Office May 2015 Foreword The is intended for use by all parties working at, attending, or visiting George Mason University. This Plan
More informationHow To File A Worker S Compensation Claim In Azoria
Workers Compensation Instructions for Filing a Claim Please complete following steps within 24 48 hours of the incident: Report the incident to your supervisor immediately or, if a medical emergency, dial
More informationHow To Write A Workers Compensation Check
WORKERS COMPENSATION Office of Human Resources WHAT IS WORKERS COMPENSATION? Workers Compensation is a University paid benefit for employees and students that are working payroll or work study. Workers
More informationFebruary Safety Subject
February Safety Subject Injury / Incident Reporting You can report hazards or make safety suggestions on the Wood County web site at www.co.wood.oh.us/employee/. Click on the Safety tab. All injuries,
More informationQUESTIONS AND ANSWERS ABOUT ILLINOIS AUTOMOBILE INSURANCE AND ACCIDENTS
QUESTIONS AND ANSWERS ABOUT ILLINOIS AUTOMOBILE INSURANCE AND ACCIDENTS What types of coverages are available? Generally, automobile insurance policies provide Bodily Injury and Property Damage Liability
More informationMotor Accident Report Form
Completing the claim form It is always important to notify your Insurer of a claim as soon as possible after an accident has occurred. Please therefore complete this form and return it to us within 14
More informationACCIDENT / INJURY REPORTING PROCEDURES FOR GEORGIA STATE UNIVERSITY
ACCIDENT / INJURY REPORTING PROCEDURES FOR GEORGIA STATE UNIVERSITY FOR ANY LIFE THREATENING EMERGENCY ** SEEK TREATMENT IMMEDIATELY THEN FOLLOW THE PROCEDURES THAT FOLLOW **LIFE THREATENING EMERGENCIES
More informationINCIDENT INFORMATION SHEET. Driver or Passenger? (please circle)
INCIDENT INFORMATION SHEET CLIENT INFORMATION Date Client Name: Driver or Passenger? (please circle) Spouse s full name, if married: Home # Work # Cell # E-Mail at home E-Mail at work Date of Birth Social
More informationSTATEMENT OF RESOURCES TO ADDRESS CLAIMS ARISING FROM ACCIDENTS INVOLVING VEHICLES OPERATED ON UNIVERSITY BUSINESS
STATEMENT OF RESOURCES TO ADDRESS CLAIMS ARISING FROM ACCIDENTS INVOLVING VEHICLES OPERATED ON UNIVERSITY BUSINESS This statement contains a general description of resources available in connection with
More informationRights & Obligations under the Nebraska Workers Compensation Law
Nebraska Workers Compensation Court Information Sheet: Rights & Obligations under the Nebraska Workers Compensation Law NEBRASKA WORKERS COMPENSATION COURT OFFICIAL SEAL What is workers compensation? Workers
More informationWorkers Compensation Informational Materials and Filing Overview
Workers Compensation Informational Materials and Filing Overview Call 911, as applicable, and/or seek medical attention as necessary. Report the incident to the supervisor/department. The supervisor/department
More informationJuly 15, 2014 STATEMENT OF RESOURCES TO ADDRESS CLAIMS ARISING FROM ACCIDENTS INVOLVING VEHICLES OPERATED ON UNIVERSITY BUSINESS
July 15, 2014 STATEMENT OF RESOURCES TO ADDRESS CLAIMS ARISING FROM ACCIDENTS INVOLVING VEHICLES OPERATED ON UNIVERSITY BUSINESS This statement contains a general description of resources available in
More informationYour Accident Fact Kit
Your Accident Fact Kit We hope you find our Accident Fact Kit helpful in the event an accident. Don't forget to keep a pen with your kit. Keep the kit in your glove box, just in case you need it. It includes:
More informationIncident Reporting Manual
Pillar Income Asset Management, Inc. Incident Reporting Manual For use in reporting: Property Losses General Liability Incidents Workers Compensation Incidents Commercial Auto Incidents Prepared by: The
More informationWhat is an insurance policy? Financial Risk: Insurance Questions and Answers. What is insurable interest? What is insurable interest?
Financial Risk: Insurance Questions and Answers What is an insurance policy? A legally binding contract Insurance company and the policyholder (person insured) In exchange for payment (premium) The insurance
More informationINSTRUCTIONS ON COMPLETING THE WORKERS COMPENSATION- FIRST REPORT OF INJURY REPORT
INSTRUCTIONS ON COMPLETING THE WORKERS COMPENSATION- FIRST REPORT OF INJURY REPORT I. GENERAL SECTION : Information to be placed in this section only by County Risk Management personnel. The General section
More informationEmergency Assistance Phone Numbers:
Thank you for purchasing the IMG OUTREACH Plan. This document includes tips for team leaders and travelers as well as resources for filing a successful claim. We highly recommend reviewing and printing
More informationConsumer Legal Guide. Your Guide to Automobile Insurance and Accidents
Consumer Legal Guide Your Guide to Automobile Insurance and Accidents WHAT TYPES OF COVERAGES ARE AVAILABLE? Generally, automobile insurance policies provide Bodily Injury and Property Damage Liability
More informationInjured at work? WHAT TO DO IF YOU ARE INJURED ON THE JOB:
Injured at work? WHAT TO DO IF YOU ARE INJURED ON THE JOB: In case of medical emergency seek immediate treatment at the nearest medical facility. tify your supervisor immediately and assist in filing a
More informationGeorgia School Boards Association. Risk Management Fund Claims Manual
Georgia School Boards Association Risk Management Fund Claims Manual July 1, 2015 - June 30, 2016 Table of Contents Section GSBA Claims Services 1 GSBA Claim Team..2 GSBA Liability Claim Reporting Procedures..3
More informationNEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW COVER LETTER POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NEW YORK MOTOR VEHICLE -FAULT INSURANCE LAW COVER LETTER NAME, ADDRESS AND PHONE NUMBER OF INSURER, SELF-INSURER OR REPRESENTATIVE* NAME, ADDRESS AND PHONE NUMBER OF CLAIM REPRESENTATIVE* POLICYHOLDER
More informationMOTOR VEHICLE CLAIM FORM
MOTOR VEHICLE CLAIM FORM (If there is not enough room on this form for your answers, please attach a separate sheet, indicating the Section and Question you wish to complete.) Please lodge your claim to
More informationMOTOR VEHICLE ACCIDENT CLAIM FORM
MOTOR VEHICLE ACCIDENT CLAIM FORM Insurer: Insured Identity No.: Occupation: Phone No.: Vehicle Reg No.: Date Purchased: Make: Tare: Gross Vehicle Mass: Kilometers: Price Paid: Value: Year: Model: If the
More information15 FAM 960 SAFETY, OCCUPATIONAL HEALTH, AND ENVIRONMENTAL MANAGEMENT (SHEM) PROGRAM REQUIREMENTS
15 FAM 960 SAFETY, OCCUPATIONAL HEALTH, AND ENVIRONMENTAL MANAGEMENT (SHEM) PROGRAM REQUIREMENTS (Office of Origin: OBO) 15 FAM 961 IMPLEMENTATION Each post abroad must implement a comprehensive safety
More informationONYX BUSINESS AUTO POLICY COVERAGE
ONYX BUSINESS AUTO POLICY COVERAGE Various provisions in this policy restrict overage Read the entire policy carefully to determine rights, duties and what is and is not covered. Throughout this policy
More informationTHE TEXAS A&M UNIVERSITY SYSTEM (TAMUS) FLEET VEHICLE USE GUIDELIINES
THE TEXAS A&M UNIVERSITY SYSTEM (TAMUS) FLEET VEHICLE USE GUIDELIINES Definitions System Fleet Manager Individual appointed by the Vice Chancellor for Business Services responsible for ensuring compliance
More informationUSE OF STATE VEHICLES
ILLINOIS PRISONER REVIEW BOARD POLICY, VEHICLE USAGE RESCINDS: N/A ESTABLISHED: 09/11/2014 RELATED DOCUMENTS: DISTRIBUTION: All PRB Board Members and employees Office/desk copy Employees working for the
More informationPUBLIC/PERSONAL LIABILITY CLAIM FORM
ACE Insurance Limited PUBLIC/PERSONAL LIABILITY CLAIM FORM McKenna Hampton Pty Ltd "Kandahar House" Level 1, 41-43 Ord Street West Perth WA 6005 PO Box 204, West Perth WA 6872 Phone: 08 6142 0000 Fax:
More informationPolicy Guideline 07 Health & Safety (Serious Injury and Incident)
Patron: The Honourable Alex Chernov AC QC Governor of Victoria Policy Guideline 07 Health & Safety (Serious Injury and Incident) Introduction 1. [Name of Organisation] recognises that the health and safety
More informationClaim form Motor Vehicle
Claim form Motor Vehicle The Company does not admit Liability by the issue of this Form. It is issued to enable the Insured to lodge their written statement of claim. CLAIM NUMBER OFFICE USE ONLY Claim
More information4. Employers Liability Claims Procedures (Accidents) 7. Public Liability/Products Liability Claims Procedures
1. Introduction 2. Contacts 3. General Claims Procedures 4. Employers Liability Claims Procedures (Accidents) 5. Document Checklist - Employers Liability 6. Employers Liability Procedures (Disease Claims)
More informationNT WORKERS COMPENSATION CLAIM FORM
Information for Workers Guidance to PART 1 of the Claim Form Notify your employer of your injury, verbally or in writing, as soon as practicable. Fully complete PART 1 (questions 1 to 8) of the following
More informationPHOENIX INSURANCE BROKERS PTY LTD ABN 40 009 419 872
STEADFAST GROUP MEMBER PHOENIX INSURANCE BROKERS PTY LTD ABN 40 009 419 872 Public Liability Insurance Claim 20 Lyall Street South Perth 6151 PO Box 961 South Perth 6951 PH: (08) 9367-7399 FAX: (08) 9367-7319
More informationMotor Vehicle Claim Form
Motor Vehicle Claim Form Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring the enclosed claim form
More informationWe thank you for your business, and look forward to providing you with the necessary protection and care for your business and employees.
RE: Workers Compensation Claims Kit Welcome to the Workers Compensation Insurance Program offered through Tower Group Companies. While we hope that your company never has to experience a workers compensation
More informationTEXAS DEPARTMENT OF CRIMINAL JUSTICE Supervisor s Report Packet for Workers Compensation CONTENTS
Supervisor s Report Packet for Workers Compensation CONTENTS PERS 299-1, Supervisor s Guidelines for Workers Compensation PERS 299-2, Witness Statement PERS 299-3, Supplemental Worksheet PERS 299 (09/15)
More informationOccupational Injury / Illness Report
Occupational Injury / Illness Report This report must be completed whenever a Franklin & Marshall employee, including a student worker, is injured or becomes ill during the course of his/her employment
More informationMotor Vehicle Claim Form
Motor Vehicle Claim Form MOTOR VEHICLE CLAIM FORM Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring
More informationPLEASURE CRAFT / HULL CLAIM FORM
PLEASURE CRAFT / HULL CLAIM FORM INSURANCE BROKERS The Issue of this Form is not an Admission of Liability by Insurer Policy # : Claim # : Please complete and return this claim form as soon as possible,
More informationYour Guide to Automobile Insurance and Accidents
Consumer Legal Guide Your Guide to Automobile Insurance and Accidents ILLINOIS STATE BAR ASSOCIATION ASK A LAWYER WHAT TYPES OF COVERAGES ARE AVAILABLE? Generally, automobile insurance policies provide
More informationWorkers Compensation claim form
Form Workers Compensation claim form STOP - this form is available to be filled in electronically on the NT WorkSafe web site www.worksafe.nt.gov.au. Fill the form in electronically then save a copy to
More informationSingapore Airlines Claim Form
Singapore Airlines Claim Form IMPORTANT NOTE: Please answer all questions contained in this claim form as leaving items blank, using ticks, dashes and N/A may make it necessary for us to return your claim
More information1.855.254.2713. Record your fleet vehicle information in the following spaces. This information will be needed when filing a claim.
1.855.254.2713 PLEASE KEEP THIS INFORMATION IN YOUR VEHICLE AT ALL TIMES These documents outline the procedures you must follow when your fleet vehicle is involved in an accident Record your fleet vehicle
More informationSMALL COMMERCIAL INSURANCE
SMALL COMMERCIAL INSURANCE Copyright 2015 by The Hartford. All rights reserved. No part of this document may be reproduced, published or posted without the permission of The Hartford. Agenda 1. The Basics:
More informationAccident & Property Accidents - What You Should Know About Insurance Claims
Contacting Us: Phone: 1-888-249-0035 Fax: 1-888-349-0035 Email: mail@bretdixonins.com Mail: Bret Dixon Insurance PO Box 205 Bethalto, IL 62010-0205 USING ACCIDENT OR INCIDENT REPORTS With most 2 nd and
More informationApplication for Witness
Compensation for Victims of Crime Program Application for Witness The Compensation for Victims of Crime Program is part of Manitoba Justice, Victim Services Branch and gives compensation to eligible witnesses
More informationNEFE High School Financial Planning Program Unit 6 Your Money: Keeping it Safe and Secure. Unit 6 - Insurance: Protecting What You Have
Unit 6 - Insurance: Protecting What You Have Common Exposures to Loss Exposure Risk Potential Loss Accident or Illness Loss of income from inability to work; uninsured medical bills; death UNLIMITED Property
More informationClaim Filing Instructions & Claim Form
Claim Filing Instructions & Claim Form Please follow these instructions prior to filing a claim and when completing the Claim Form. Assistance is also available from the International Medical Group (IMG
More informationHow To Report An Accident In Spokane County
Spokane County Accident Prevention Program 1.7 ACCIDENT REPORTING POLICY I. SCOPE Policy No. 1.7 Revised: August 2007 Reporting accidents/incidents that result in an injury to a Spokane County employee,
More informationWe thank you for your business, and look forward to providing you with the necessary protection and care for your business and employees.
RE: Workers Compensation Claims Kit Welcome to the Workers Compensation Insurance Program offered through Tower Group Companies. While we hope that your company never has to experience a workers compensation
More informationTable of Contents. 2042.51 Scope. 1 2042.52 General. 1 2042.53 Motor vehicle (including aircraft) accidents. 2
Table of Contents PART 2042 - TORT CLAIMS SUBPART B - Reporting Accidents Table of Contents Sec. Page 2042.51 Scope. 1 2042.52 General. 1 2042.53 Motor vehicle (including aircraft) accidents. 2 (a) Accidents
More informationHome and Contents Insurance Claim. and. corporate. Title Surname Full given name(s) Postcode Contact home phone number. Contact facsimile number ( )
BankSA Home and Contents Insurance Claim About this form Only About complete this form this form if your claim is in respect to loss of or damage to Buildings/Contents/Personal Valuables or Legal Liability.
More informationWorkers' Compensation CLAIMS KIT
Workers' Compensation CLAIMS KIT CLMCVR ATTENTION WORKERS' COMPENSATION POLICYHOLDERS! Thank you for placing your Workers' Compensation insurance through CIA Managing General Agency. The carrier for your
More informationWorkers Compensation
Workers Compensation All work-related injuries or illnesses must be reported. If the injury is an emergency, arrange for appropriate medical treatment. The employee has the right to select his or her own
More informationChapter 14 Project Incidents and Complaints
Chapter 14 Project Incidents and Complaints 1-1401 Reporting Complaints and Damage or Injury Claims Complaints or claims for personal injury or damage to property because of project details or the operations
More informationThe issue and acceptance of this form does NOT constitute an admission of liability by ACE or waiver of its rights. Email Name of Agent/Broker
WORK INJURY COMPENSATION Claim Form IMPORTANT INFORMATION 1) Insured is requested to state, as fully and accurately as possible, the information asked for below. *SG011* *SG011* 2) If any detail or information
More informationTo: Our Valued Clients From: Agency Name Re: Gap Letter
To: Our Valued Clients From: Agency Name Re: Gap Letter From time to time, we mail a notice to our clients (past, current, and potential) called a Gap Letter. The purpose of this letter is to inform you
More informationWhat is a definition of insurance?
What is a definition of insurance? A system of protection against loss in which a number of individuals agree to pay certain sums for a guarantee that they will be compensated for a specific loss. Every
More informationThe issuance and acceptance of this form does NOT constitute an admission of liability by ACE Insurance Limited (ACE) or waiver of its rights.
HOME INSURANCE Claim Form *SG011* *SG011* IMPORTANT INFORMATION The information requested and documents mentioned in this form are a general guide. Further documents or information may be required depending
More informationCLAIM FORM A. To be completed by the registered operator/ owner or driver of the vehicle
Notice of Accident CLAIM FORM A To be completed by the registered operator/ owner or driver of the vehicle If you have suffered Personal Injury resulting directly from this motor accident and wish to claim
More informationChecklist for personal accident, overseas student or foreign maid claim
Checklist for personal accident, overseas student or foreign maid claim Dear person claiming We are sorry to learn of your illness, injury or stay in hospital. Please send us all the documents listed below.
More informationWorkers Compensation Claim Kit PRAIRIE STATE INSURANCE COOPERATIVE
Workers Compensation Claim Kit PRAIRIE STATE INSURANCE COOPERATIVE A CMI, A York Risk Services Company, publication November 1, 2013 Table of Contents About CMI.... 1 To Report a Claim... 1 The Importance
More informationInjury and Work- Related Illness Prevention Program
Associated Students, California State University, Northridge, Inc. Injury and Work- Related Illness Prevention Program 1. PURPOSE STATEMENT It is the intention of the Associated Students, California State
More informationWORK INJURY BENEFIT CLAIM FORM
WORK INJURY BENEFIT CLAIM FORM Important information please read carefully i. This report is to be completed by the employer in case of injury to or death of a workman and returned back along with the
More informationOffice of Physical Plant
Office of Physical Plant The Pennsylvania State University Physical Plant Building University Park, PA 16802-1118 Please have the employee complete this Workers Compensation Signature Packet as soon as
More informationAcalanes Union HSD Board Policy Work-Related Injuries
Board Policy BP 4157.1 District employees shall be insured for on-the-job specific or cumulative injuries in accordance with law. In order to reduce costs and facilitate employee recovery, the Governing
More informationVERSABAR SAFETY MANAGEMENT SYSTEM
INCIDENT MANAGEMENT AND REPORTING 1 PURPOSE VERSABAR SAFETY MANAGEMENT SYSTEM (C-01) INCIDENT MANAGEMENT The purpose of this section is to provide the Management Team with clear directions and procedures
More informationBasildon Council - Motor Vehicle Claim Form
Basildon Council - Motor Vehicle Claim Form Please ensure you read the following information before completing this claims form and that you complete this form thoroughly, failure to complete the form
More informationPart 1 To be filled in by the worker. The following information is provided as guidance to workers filling in Part 1.
Form Workers compensation claim form Part 1 To be filled in by the worker. The following information is provided as guidance to workers filling in Part 1. Notify your employer of your injury or disease
More informationCLAIMS REPORTING KIT. Administered by
CLAIMS REPORTING KIT Administered by 451 Diamond Drive Ephrata, Washington 98823 (509) 754-2027; Fax (509) 754-3406 Toll Free (800) 407-2027 Report all accidents and losses as soon as possible to your
More informationForm Workers compensation claim form
Form Workers compensation claim form Part 1 of the claim form is to be filled in by the worker. The following information is provided as guidance to workers filling in Part 1 Notify your employer of your
More informationFor the purpose of this Procedure the following definitions will apply:
Procedure 6.5: Workplace Safety and Injury Reporting Volume 6 Managing Office: Office of Human Resources Effective Date: March 15, 2011 Revised: June 2014 I. GENERAL POLICY Alabama A&M University ( AAMU
More informationMOTOR VEHICLE CLAIM FORM
MOTOR VEHICLE CLAIM FORM Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring the enclosed claim form
More informationGuide. CLAIM FOR death benefits TO THE. Claim Number DID A 7266A 45 (2014-09)
Guide TO THE CLAIM FOR death benefits Claim Number DID A 7266A 45 (2014-09) Compensation paid by the SAAQ I Compensation paid by the SAAQ The various death benefits paid by the SAAQ are the following:
More informationMichigan Property & Casualty Guaranty Association P.O. Box 531266 Livonia, Michigan 48153-1266 Phone: (248) 482-0381
Michigan Property & Casualty Guaranty Association P.O. Box 531266 Livonia, Michigan 48153-1266 Phone: (248) 482-0381 Dear Claimant: The Michigan Property & Casualty Guaranty Association ("the MPCGA") is
More informationAP#8, DCFS MOTOR LIABILITY PLAN September 1, 1997 P.T. 97.28
SECTION 8.1 Purpose 8.2 Motor Vehicle Liability Plan 8.3 General Provisions 8.4 Employee Responsibilities 8.5 Required Reporting Forms and Information to Be Obtained 8.6 Supervisor I Management Responsibilities
More informationLiability Claims Guidance Notes
Liability Claims Guidance Notes It is important that you read and understand these guidance notes before When can a claim be made against the Council? completing the claim form To successfully claim compensation
More informationMOTOR VEHICLE USE POLICY
MOTOR VEHICLE USE POLICY A university vehicle is defined as a vehicle which is self-propelled and is owned, leased or rented by the university. University vehicles shall be used only in the conduct of
More informationWORKERS' COMPENSATION INFORMATION
Carnegie Mellon University Human Resources Benefits & Compensation Office 5000 Forbes Avenue, 319 SCRG Pittsburgh, PA 15213-3730 (412) 268-2047 Fax: (412) 268-7472 WORKERS' COMPENSATION INFORMATION In
More informationMotor Vehicle Claim Form
1st Floor, 50 Hindmarsh Square Adelaide SA 5000 PO Box 6095 Halifax St Adelaide 5000 Phone 08 8413 6300 Facsimile 08 82119838 enquiries@brecknock.com.au brecknock.com.au Motor Vehicle Claim Form We re
More informationMotor Vehicle Claim Form
SSAA Insurance Brokers Pty Ltd Phone (08) 8332 0281 The Precinct Freecall 1800 808 608 Suite 14, 539 Greenhill Road Facsimile (08) 8332 0303 539 Greenhill Road Email insurance@ssaains.com.au Hazelwood
More informationWC-1 EMPLOYER S REPORT OF INDUSTRIAL INJURY
Every work injury to an employee causing abscence for one day or more or which requires medical services other than first aid treatment must be reported within 7 working days after the injury. Failure
More informationAutomobile Fleet Safety Manual. William Gallagher Associates Automobile Fleet Manual 1
Automobile Fleet Safety Manual William Gallagher Associates Automobile Fleet Manual 1 Table Of Contents Mission Statement 3 Company Rules and Regulations 4-5 Driver Qualifications 6 Drivers Licenses 6
More information