Let Trustpoint Insurance help you reduce the impact of claims. CLAIM REPORTING FORM Step 1 of 9 - General Policy 11% Policyholder and Contact InformationNamed Insured*The name as it appears on the declarations page of the policy.Poliicy Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Standard Industry Code (SIC)Employer Federal Identification Number (FEIN)Name of person completing this form.*Title of person completing this form. Contact Person This should be the person we communicate with to obtain additional information about this claim.Are you (person completing this form) also the Contact Person?*YesNoContact Person Name*Contact Person Email Contact Person Phone*The contact person be reached at:*If other please provide details.Policy AddressClaim AddressOtherWhat is the best time to reach contact person?Contact Person Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date/Time and Type of LossAddress of Claim Location*Place where damage to your property or alleged injury or accident occurred. If not a specific street address, please describe location. Like intersection or lot number. Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Loss*Enter the date this accident, incident, damage or injury occurred or was alleged to have occurred on. Date Format: MM slash DD slash YYYY Can the time of this accident, incident, damage or injury be determined?*YesNoTime of Loss*Enter the time (or estimated time) this accident, incident, damage or injury occurred on or was alleged to have occurred on. : HH MM AM PM Were police/fire/EMT department(s) contacted?*YesNoName of police/fire/EMT department(s).*Police/fire/EMT deptartment report #.Type of Insurance Policy/Coverage*Property - Damage to your building or contents.General Liability - Injury to others or damage to their property.Automobile - an accident involving your vehicle or driver.Workers Compensation - an injury to one of your employees.Insurance Policy InformationProperty Insurance Company*Property Insurance Polciy Number*Property Insurance Effective Date* Date Format: MM slash DD slash YYYY Property Insurance Expiration Date* Date Format: MM slash DD slash YYYY General Liability Insurance Company*General Liability Insurance Polciy Number*General Liability Insurance Policy Effective Date* Date Format: MM slash DD slash YYYY General Liability Insurance Policy Expiration Date* Date Format: MM slash DD slash YYYY Automobile Insurance Company*Automobile Insurance Polciy Number*Automobile Insurance Policy Effective Date* Date Format: MM slash DD slash YYYY Automobile Insurance Policy Expiration Date* Date Format: MM slash DD slash YYYY Worker's Compensation Insurance Company*Worker's Compensation Insurance Polciy Number*Worker's Compensation Insurance Policy Effective Date* Date Format: MM slash DD slash YYYY Worker's Compensation Insurance Policy Expiration Date* Date Format: MM slash DD slash YYYY Property Loss DetailsDescribe the damaged property.*For example, building, personal property, equipment.Cause of Loss*This list does not necessarily indicate coverage availablity under your policy.FireLightningWindHailFloodTheftProvide a brief narrative description of the loss.* Liability Loss DetailsType of Liability Coverage*This list does not necessarily indicate coverage under your policy.PremisesAn accident causing injury to another person or damage to their property.ProductsInjury or another person or damage to their property caused by your product.Something Else or Not SureNot a problem, we can determine this later.Type of premises or Product*Type of Allegation*Property DamageDamage to another persons's property.Bodily InjuryPhysical Injury to another personPersonal InjuryNon physical inury to another personOther Injury or Not SureWe can determine proper type later.Name of the injured party or owner of damaged property.*Phone number of injured party or owner of damaged property.Email of injured party or owner of damaged property. Address for injured party or owner of damaged property. Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Describe the property damaged by this occurrence.*Where can this damaged property be seen?*Describe the injury.*What was the person doing at the time of injury.*Injured Party's AgeInjured Party's GenderMaleFemaleOtherInjured Party's OccupationIf the injured party received treatment, please describe.Include name of hospital or emergency room if known.Tell us about the nature of injury or property damage.*Describe the circumstances that led to allegations and the resulting injury or damage.Estimated amount of loss.If known let us know how much is being claimed for the bodily injury or damed property.Value of goodwill efforts.*Other*Has the claimant/party alleging injury made a specific request?* None Acknowledgement of circumstances Contact from insurance adjuster Reimbursement of medical bills Reimbursement of expenses Other / Speciffied compensation Estimated cost of requests.*Other* Automobile Loss DetailsPurpose of UseDescribe how the vehicle was being used at the time of the accident or damage. (i.e. transporting guest, running a business errand, personal use)Describe the accident or how damage occurred to vehicle.*Describe the damage to your vehicle.*Estimated amount of damage to your vehicle.Where can your vehicle be seen?How many people were injured?*None1234More than 4Was another vehicle involved?*YesNoWas there other property damage?*This is property other than vehicles.YesNo Your Insured Vehicle (IV) InformationIV YearIV MakeIV ModelIV V.I.N.IV Plate Number Your Driver InformationIV Driver's Name*IV Driver's License Number Automobile Loss Details - ContinuedDescribe damage to other vehicle.*Estimated amount of damage to other vehicle.Where can the other vehicle be seen?Describe damage to other property.*This is property other than vehicles. Include a description of the property itself.Estimated amount of damage to other property. Other Vehicle (OV) InformationOV YearOV MakeOV ModelOV V.I.N.OV Plate Other Driver InformationOV Driver's NameOV Driver's License Number Injured Party Information1. Injured Party Name1. Extent of Injurires1. Injured Party Contact Information2. Injured Party Name2. Extent of Injurires2. Injured Party Contact Information3. Injured Party Name3. Extent of Injurires3. Injured Party Contact Information4. Injured Party Name4. Extent of Injurires4. Injured Party Contact InformationPlease attach a list of injured parties including their names, extent of injuries and contact information. You will be able to upload additional documents at the end of this form. Worker's Compensation Loss DetailsInsured Report NumberIf you have an internal report number assigned to this incident, please enter it here.OSHA Case NumberIf you have reported this incident to OSHA, please enter the case number here. Employee and Wage InformationEmployee Name (Last, First, Middle)*PhoneEmployee Email Employee Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Occupation/Job Title*Employment Status*Full-TimePart-TimeNot EmployedOn StrikeDisabledRetiredApprenticeship Full-TimeApprenticeship Part-TimeVolunteerSeasonalPiece WorkerEmployee Worker's Compensation Class Codeeg. 8810 ClericalDate Hired Date Format: MM slash DD slash YYYY State Hired*Social Security NumberDate of Birth Date Format: MM slash DD slash YYYY Sex*MaleFemaleUnknownMarital StatusSingle/DivorcedMarriedSeparatedUnknown# of DependentsRatePer*HourDayWeekMonthYearAverage Weekly Rate# Days Worked/WeekTime employee started work the day of accident. : HH MM AM PM Did employee miss any time from work?*YesNoFuture Major Medical / Lost Time Anticipated?*YesNoLast date worked due to injury. Date Format: MM slash DD slash YYYY Date returned (or expected) to work. Date Format: MM slash DD slash YYYY Did salary continue?YesNo Injury and Treatment InformationInitial treatment administered to employee.*No Medical TreatmentMinor by EmployerMinor Clinic / Phys OfficeEmergency Care / HospitalOvernight HospitalizationPhysician's Name*Physician's Contact Information*Hospital/Clinic Name*Hospital/Clinic Contact Information*Did this accident result in death or disability to the employee.*Yes - DeathYes - DisabilityNoDate of Death* Date Format: MM slash DD slash YYYY Date Disability Began* Date Format: MM slash DD slash YYYY Injury Type*Specific InjuryOccupational Disease / Cumulative InjuryMultiple InjuriesSpecific Injury Types*No Physical InjuryAmputationAngina PectorisBurnConcussionContusionCrushingDislocationElectric ShockEnucleationForeign BodyFractureFreezingHearing Loss or ImpairmentHeat ProsrtrationHerniaInfectionInflammationLacerationMyocardial InfarctionPoisoning - General (NOT OD OR CUMUL)PunctureRuptureSeveranceSprainStrainSyncopeAsphyxiationVascularVision LossAll Other Specific Injuries, NOCOccupational Disease / Cumulative Types*Dust Disease, NOCAsbestosisBlack LungByssinosisSilicosisRespiratory DisordersPoisoning - Chemical (Other Than Metals)Poisoning - MetalDermatitisMental DisorderRadiationAll Other Occupational Disease Injury, NOCLoss of HearingContagious DiseaseCancerAIDSVDT Related DiseaseMental StressCarpal Tunnel SyndromeHepatitis CAll Other Cumulative Injury, NOCMultiple Injury Types*Multiple Physical Injuries OnlyMultiple Both Physical and PsychologicalBody Part Injured*HeadNeckUpper ExtremitiesTrunkLower ExtremitiesMultiple Body PartsHead Injury*Multiple Head InjurySkullBrainEar(s)Eyes(s)NoseTeethMouthSoft TissueFacial BonesNeck Injury*Multiple NeckVertebraeDiscSpinal CordLarynxSoft TissueTracheaUpper Extremities Injury*Multiple Upper ExtremitiesUpper ArmElbowLower ArmWristHandFinger(s)ThumbShoulder(s)Wrist(s) & Hand(s)Trunk Injury*Multiple TrunkUpper Back AreaLower Back AreaDiscChestSacrum and CoccyxPelvisSpinal CordInternal OrgansHeartLungsAbdomenButtocksVertebra NOCLower Extremities Injury*Multiple Lower ExtremitiesHipUpper LegKneeLower LegAnkleFootToesGreat ToeMultiple Body Parts Injury*No Physical InjuryMultiple Body Parts (Including Body Systems & Body Parts)Body Systems and Multiple Body SystemsCause of Injury*Burn/Scald - Heat/Cold Exposures or ContactCaught In, Under, or BetweenCut, Puncture, Scrape - Injured ByFall, Slip, or Trip InjuryMotor VehicleStrain or Injury ByStriking Against or Stepping OnStruck or Injured ByMiscellaneous CausesRubbed or Abraded ByBurn/Scald - Heat/Cold Exposure Cause of Injury*Abnormal Air PressureChemicalsCold Objects or SubstancesDust, Gases, Fumes, or VaporsElectrical CurrentFire or FlameHot Objects or SubstancesRadiationSteam or Hot FluidsTemperature ExtremesWelding OperationContact With, NOCCaught In, Under, or Between Cause of Injury*Collapsing Materials (Slides of Earth)Machine or MachineryObject HandledCaught In, Under, or, Between, NOCCut, Puncture, Scrape Cause of Injury*Broken GlassHand Tool, Utensil; Not PoweredObject Being Lifted or HandledPowered Hand Tool, ApplianceCut, Puncture, Scrape, NOCFall, Slip or Trip Cause of Injury*From Different Level (Elevation)From Ladder or ScaffoldingFrom Liquid or Grease SpillsInto OpeningsOn Ice or SnowOn Same LevelOn StairsSlipped, Did Not FallFall, Slip, or Trip, NOCMotor Vehicle Cause of Injury*Collision or Sideswipe With Another VehicleCollision with a Fixed ObjectCrash of AirplaneCrash of Rail VehicleCrash of Water VehicleVehicle UpsetMotor Vehicle, NOCStrain Cause of Injury*Continual NoiseHolding or CarryingJumpingLiftingPushing or PullingReachingRepetitive MotionTwistingUsing Tool or MachineryWielding or ThrowingStrain or Injury, NOCStriking Against Cause of Injury*Moving Part of MachineObject Being Lifted or HandledSanding, Scraping, Cleaning OperationStationary ObjectStepping on Sharp ObjectStriking Against or Stepping On , NOCStruck By Cause of Injury*Animal or InsectExplosion or Flare BackFalling or Flying ObjectFellow Worker; PatientHand Tool or Machine in UseMoving Parts of MachineObject Being Lifted or HandledObject Handled by OthersStruck or Injured, NOCMiscellaneous Cause of Injury*Absorption, Ingestion or Inhalation, NOCForeign Matter (Body) in Eye(s)MoldNatural DisastersOther Than Physical 1Person in Act of a CrimeTerrorismOther - Miscellaneous, NOCCumulative, NOCRubbed or Abraded Cause of Injury*Repetitive MotionRubbed or Abraded, NOCDepartment / Location*Describe the department or specific part of the premises the employee was working in at the time of the accident/injury.Specific activity/work process employee was engaged in when the accident or illness exposure occurred.All equipment, materials or chemicals employee was using when accident or illness exposure occurred.Were safeguards or safety equipment provided?*YesNoWere they used?*YesNoHow injury or illness / abnormal health condition occurred. Describe the sequence of events and include any objects or substances that directly injured the employee or made the employee ill. Witness InformationHow many witnesses saw the accident, injury or damage occur?*None12345 or more1st Witness Name*1st Witness Phone2nd Witness Name*2nd Witness Phone3rd Witness Name*3rd Witness Phone4th Witness Name*4th Witness PhonePlease attach a list of witnesses including their names and contact information. You will be able to upload additional documents in the next section of this form.Upload DocumentsIf you have documents to upload such as: photos, police/fire reports, pest reports, guest folio, injured parties/passenger lists or witness lists, you may do so here.Select files to upload. Drop files here or State Required Legal NoticesPlease scroll to the bottom after reading to submit your completed form.Applicable in Virginia: 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.
