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 ProductionInsurance.com
  A Service of Supple-Merrill & Driscoll, Inc.

 

  

 

 Non-Workers Compensation Claim Reporting Instructions

  1. Claims should be reported immediately.

  2. Please provide as much information as possible to expedite the claim reporting.

  3. Please include a narrative of the occurrence leading to the loss.

  4. Please complete this form for each loss. 

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Policyholder Information

Name of Individual/Company/Organization:
Full Name of Person to Contact:
Number:
Fax:

Email:

We will never rent, sell, or share your email address.

Full Name of Person Submitting Claim:
Policy Information
Production Title / Event Name:
Quote / Policy Number:
Policy Type:

Loss Details

Date of Loss:

Type of Loss:

If Other

Report Number:

If Any

I.E. Fire, Police, Etc.

Estimated Loss Value:

Automobile Loss
Name of Vehicle Owner:
Year, Make, Model & License of Damaged Vehicle:

Rented Vehicle Non-Owned Vehicle

Driver Name:
Driver License Number & State of Issue:
Driver Date of Birth:

Location of Loss
Name of Location:
Street Address:
City, State: ,
Zip/Postal Code:

Describe Location of Loss if Not at Specific Street Address:

 

 

Loss Narrative
Please provide a detailed description of the events surrounding the loss below.

 

 

  

 

  

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