DESCRIBE LOCATION OF OCCURRENCE IF NOT AT SPECIFIC STREET ADDRESS:
REPORT NUMBER
POLICE OR FIRE DEPARTMENT CONTACTED
COUNTRY:
CITY, STATE, ZIP:
STREET:
LOCATION OF OCCURRENCE
DESCRIPTION OF OCCURRENCE (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
OCCURRENCE
PHONE #
CELLHOME BUS
PRIMARY
PHONE #
SECONDARY
CELLHOME BUS
SECONDARY E-MAIL ADDRESS:
PRIMARY E-MAIL ADDRESS:
NAME OF INSURED (First, Middle, Last) INSURED'S MAILING ADDRESS
FEIN (if applicable)DATE OF BIRTH
INSURED
PHONE #
CELLHOME BUS
PRIMARY
PHONE #
SECONDARY
CELLHOME BUS
SECONDARY E-MAIL ADDRESS:
PRIMARY E-MAIL ADDRESS:
NAME OF CONTACT (First, Middle, Last) CONTACT'S MAILING ADDRESS
CONTACT CONTACT INSURED
WHEN TO CONTACT
INSURED LOCATION CODE DATE OF LOSS AND TIME
AM
PM
NAIC CODECARRIER
POLICY NUMBER
FAX
(A/C, No):
AGENCY
NAME:
CONTACT
(A/C, No, Ext):
PHONE
SUBCODE:CODE:
AGENCY CUSTOMER ID:
ADDRESS:
E-MAIL
DATE (MM/DD/YYYY)
GENERAL LIABILITY NOTICE OF OCCURRENCE / CLAIM
SECONDARY E-MAIL ADDRESS:
SECONDARY E-MAIL ADDRESS:
PRIMARY E-MAIL ADDRESS:
PRIMARY E-MAIL ADDRESS:
PHONE #
CELLHOME BUS
PRIMARY
PHONE #
SECONDARY
CELLHOME BUS
PHONE #
CELLHOME BUS
PRIMARY
PHONE #
SECONDARY
CELLHOME BUS
TYPE OF LIABILITY
TENANT
OWNER
PREMISES: INSURED IS
TYPE OF PREMISES
OWNER'S NAME & ADDRESS (If not insured)
VENDORMANUFACTURER
PRODUCTS: INSURED IS
TYPE OF PRODUCT
MANUFACTURER'S NAME & ADDRESS (If not insured)
WHERE CAN PRODUCT BE SEEN?
The ACORD name and logo are registered marks of ACORD
ACORD 3 (2012/05) Page 1 of 4 © 1986-2012 ACORD CORPORATION. All rights reserved.
ACORD 3 (2012/05) Page 2 of 4
REPORTED BY
REPORTED TO
REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
SECONDARY E-MAIL ADDRESS:
PRIMARY E-MAIL ADDRESS:
SECONDARY E-MAIL ADDRESS:
PRIMARY E-MAIL ADDRESS:
PHONE #
CELLHOME BUS
PRIMARY
PHONE #
SECONDARY
CELLHOME BUS
PHONE #
CELLHOME BUS
PRIMARY
PHONE #
SECONDARY
CELLHOME BUS
NAME & ADDRESS (Injured/Owner)
AGE SEX OCCUPATION
EMPLOYER'S NAME & ADDRESS
WHAT WAS INJURED DOING?WHERE TAKEN
DESCRIBE INJURY
ESTIMATE AMOUNT
WHERE CAN PROPERTY BE SEEN?
INJURED / PROPERTY DAMAGED
DESCRIBE PROPERTY (Type, model, etc.)
AGENCY CUSTOMER ID:
PHONE #
CELLHOME BUS
PRIMARY
PHONE #
SECONDARY
CELLHOME BUS
SECONDARY E-MAIL ADDRESS:
PRIMARY E-MAIL ADDRESS:
NAME AND ADDRESS
PHONE #
CELLHOME BUS
PRIMARY
PHONE #
SECONDARY
CELLHOME BUS
SECONDARY E-MAIL ADDRESS:
PRIMARY E-MAIL ADDRESS:
NAME AND ADDRESS
PHONE #
CELLHOME BUS
PRIMARY
PHONE #
SECONDARY
CELLHOME BUS
SECONDARY E-MAIL ADDRESS:
PRIMARY E-MAIL ADDRESS:
NAME AND ADDRESS
WITNESSES
ACORD 3 (2012/05)
APPLICABLE IN KANSAS
Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it
will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of,
an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or
other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially
false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act.
APPLICABLE IN THE DISTRICT OF COLUMBIA
Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other
person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information
materially related to a claim was provided by the applicant.
APPLICABLE IN INDIANA
APPLICABLE IN HAWAII
APPLICABLE IN IDAHO
APPLICABLE IN FLORIDA
APPLICABLE IN COLORADO
APPLICABLE IN CALIFORNIA
APPLICABLE IN ARIZONA
AGENCY CUSTOMER ID:
Pursuant to S. 817.234, Florida Statutes, any person who, with the intent to injure, defraud, or deceive any insurer or insured,
prepares, presents, or causes to be presented a proof of loss or estimate of cost or repair of damaged property in support of a claim
under an insurance policy knowing that the proof of loss or estimate of claim or repairs contains any false, incomplete, or misleading
information concerning any fact or thing material to the claim commits a felony of the third degree, punishable as provided in
S. 775.082, S. 775.083, or S. 775.084, Florida Statutes.
APPLICABLE IN ALASKA
A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete,
or misleading information may be prosecuted under state law.
For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or
fraudulent claim for payment of a loss is subject to criminal and civil penalties.
For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or
fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages.
Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or
information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with
regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the
Department of Regulatory Agencies.
For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a
crime punishable by fines or imprisonment, or both.
A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading
information commits a felony.
Any person who knowingly and with intent to defraud any insurance company or another person, files a statement of claim containing
any materially false information, or conceals for the purpose of misleading, information concerning any fact, material thereto, commits
a fraudulent insurance act, which is a crime, subject to criminal prosecution and [NY: substantial] civil penalties. In LA, ME, TN, and
VA, insurance benefits may also be denied.
APPLICABLE IN ARKANSAS, DELAWARE, KENTUCKY, LOUISIANA, MAINE, MICHIGAN, NEW JERSEY,
NEW MEXICO, NEW YORK, NORTH DAKOTA, PENNSYLVANIA, RHODE ISLAND, SOUTH DAKOTA,
TENNESSEE, TEXAS, VIRGINIA, AND WEST VIRGINIA
Any person who knowingly and with the intent to injure, defraud, or deceive any insurance company files a statement of claim
containing any false, incomplete or misleading information is guilty of a felony.
Page 3 of 4
ACORD 3 (2012/05)
Any person who knowingly and [or]* willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and
[or]* willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement
in prison. * [or] effective 01-01-2013
APPLICABLE IN MINNESOTA
APPLICABLE IN MARYLAND
A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
APPLICABLE IN NEVADA
Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete or
misleading information concerning a material fact is guilty of a felony.
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding
the company. Penalties include imprisonment, fines and denial of insurance benefits.
APPLICABLE IN WASHINGTON
APPLICABLE IN OHIO
APPLICABLE IN NEW HAMPSHIRE
AGENCY CUSTOMER ID:
APPLICABLE IN OKLAHOMA
WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of
an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Any person who, with purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false,
incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.
Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a
claim containing a false or deceptive statement is guilty of insurance fraud.
Page 4 of 4
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