Fillable GENERAL LIABILITY NOTICE OF OCCURRENCE / CLAIM (Crum & Forster Insurance)

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GENERAL LIABILITY NOTICE OF OCCURRENCE / CLAIM (Crum & Forster Insurance)

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Country of origin: US
File type: PDF

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DATE (MM/DD/YYYY)
AGENCY
PREVIOUSLY
PHONE
DATE OF OCCURRENCE AND TIME DATE OF CLAIM
(A/C, No, Ext):
REPORTED
EFFECTIVE DATE EXPIRATION DATE POLICY TYPE RETROACTIVE DATE
COMPANY MISCELLANEOUS INFO (Site & location code)
NAIC CODE:
FAX
(A/C, No):
E-MAIL
ADDRESS:
POLICY NUMBER REFERENCE NUMBER
CODE: SUB CODE:
AGENCY
CUSTOMER ID:
NAME AND ADDRESS NAME AND ADDRESS WHERE TO CONTACT
SOC SEC # OR FEIN:
WHEN TO CONTACT
RESIDENCE PHONE (A/C, No) BUSINESS PHONE (A/C, No, Ext) RESIDENCE PHONE (A/C, No) BUSINESS PHONE (A/C, No, Ext)
CELL PHONE (A/C, No) E-MAIL ADDRESS CELL PHONE (A/C, No) E-MAIL ADDRESS
AUTHORITY CONTACTED
LOCATION OF
OCCURRENCE
(Include city & state)
DESCRIPTION OF
OCCURRENCE
(Use separate sheet,
if necessary)
COVERAGE PART OR
FORMS (Insert form
#s and edition dates)
GENERAL AGGREGATE PROD/COMP OP AGG PERS & ADV INJ EACH OCCURRENCE FIRE DAMAGE MEDICAL EXPENSE DEDUCTIBLE
UMBRELLA/
CARRIER: LIMITS:
EXCESS
TYPE OF PREMISES
PREMISES: INSURED IS
OWNER’S NAME
& ADDRESS
(If not insured)
OWNERS PHONE
(A/C, No, Ext):
TYPE OF PRODUCT
PRODUCTS: INSURED IS
MANUFACTURER’S
NAME & ADDRESS
(If not insured)
MANUFACT PHONE
(A/C, No, Ext):
WHERE CAN PRODUCT BE SEEN?
OTHER LIABILITY IN-
CLUDING COMPLETED
OPERATIONS (Explain)
PHONE (A/C, No, Ext)
NAME &
ADDRESS
(Injured/Owner)
AGE SEX OCCUPATION PHONE (A/C, No, Ext)
EMPLOYER’S
NAME &
ADDRESS
DESCRIBE INJURY WHERE TAKEN WHAT WAS INJURED DOING?
ESTIMATE AMOUNT WHEN CAN PROPERTY BE SEEN?
DESCRIBE WHERE CAN
PROPERTY PROPERTY
(Type, model, etc) BE SEEN?
NAME & ADDRESS BUSINESS PHONE (A/C, No, Ext) RESIDENCE PHONE (A/C, No)
REMARKS
REPORTED BY REPORTED TO SIGNATURE OF INSURED SIGNATURE OF PRODUCER
NOTICE OF
AM
OCCURRENCE
NOTICE OF CLAIM PM YES NO
OCCURRENCE CLAIMS MADE
CONTACT INSURED
PD
BI
PER SIR/
UMBRELLA EXCESS AGGR
CLAIM/OCC DED
OWNER TENANT OTHER:
MANUFACTURER VENDOR OTHER:
FATALITY
INSURED CONTACT
OCCURRENCE
POLICY INFORMATION
TYPE OF LIABILITY
INJURED/PROPERTY DAMAGED
WITNESSES
GENERAL LIABILITY NOTICE OF OCCURRENCE / CLAIM
08/04/2016
Submit By Email
* In Florida - Third Degree Felony
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.
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 DC, LA, ME, TN and VA, insurance benefits may also be denied.
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.
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.*
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.
A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
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.
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.
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.
Applicable in Arizona
Applicable in Arkansas, Delaware, District of Columbia, Kentucky, Louisiana,
Maine, Michigan, New Jersey, New Mexico, New York, North Dakota, Pennsylvania,
South Dakota, Tennessee, Texas, Virginia and West Virginia
Applicable in California
Applicable in Colorado
Applicable in Florida and Idaho
Applicable in Hawaii
Applicable in Indiana
Applicable in Minnesota
Applicable in Nevada
Applicable in New Hampshire
Applicable in Ohio
Applicable in Oklahoma
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GENERAL LIABILITY NOTICE OF OCCURRENCE CLAIM (Crum & Forster Insurance)

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Completed 13 July 2021

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