Errors and Omissions Report Form

2941 Foothill Blvd • La Crescenta, CA 91214 • Phone: 818-248-1511
Errors and Omissions Report Form
To report an incident that could result in a claim to Archer Travel Service, Inc., please complete the following information and submit.

*Please note, in order to be in compliance with the claim/incident reporting section of your policy, your claim must be reported in writing and include ALL of the information below to constitute a notice to Archer Travel Serrvice, Inc. A description given by phone or an incomplete report will not satisfy the reporting requirements of the policy.*
Evo Agent Name

First NameLast Name
Evo Agent ID Number
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Name of person/company making the claim against you
Date of occurrence/error/incident giving rise to the claim/potential claim

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Date you were first notified /contacted by the claimant or their representative about this matter

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Have you previously reported this claim/incident/potential claim to Archer Travel Service, Inc.?
Date this was previously reported

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Has a suit been brought against you?
Date of the suit

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Date you were served

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Amount of demand (if any) or amount at issue ($)
Required Deductible amount $1,500 USD.

Demand must be equal to or greater than $1,500 USD
Brief description of the allegations against you (attach an additional page if necessary). Please include a brief summary here, even if this information is included in any paperwork you are attaching.

0/200
Important: Please attach to this form any and all correspondence any insured has received concerning this matter, including but not limited to: emails, demand letter, notice(s) from your underwriter, summons, complaint, or other papers, etc.

Please gather and retain your complete file(s) regarding the transaction(s) involved in the incident or claim, including all correspondence and emails with anyone that relates to the transaction(s), incident, or claim.
Supporting Documents

Cancelof
Signature
Should be Empty: