CRL First Notice of Claim Form
Please complete this form and submit along with the neccessary documents.
Member Information:
State:
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
County(ies):
CRL Member Pool Name:
Primary Adjuster's Name:
Primary Adjuster's Email Address:
example@example.com
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Coverage Type:
Please Select
Auto Liability
Cyber Liability
General Liability
Law Enforcement Liability
Property
Public Officials/E&O/Employment Practices
Workers' Compensation
Employer Liability (Rare)
Employer Liability WC (Rare)
Policy Inception Date:
-
Month
-
Day
Year
Date
Policy Type
Please Select
Claims Made
Occurrence Made
Unknown
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Date of Loss:
-
Month
-
Day
Year
Date
Member Claim Number:
Are there multiple claimants under one claim?
Please Select
Yes
No
Claimant Name:
First Name
Last Name
Additional Claimant Name(s)
Property/Claim Name(s):
Is this a CAT?
Yes
No
CAT #:
Was a claim filed with the member or the county?
Please Select
Yes
No
Date claim was filed:
-
Month
-
Day
Year
Date
Claim Description:
Provide additonal supporting documents via the document upload section.
CRL Report Reason(s):
Does this require notice to an excess carrier?
Yes
No
Excess Carrier Reporting Data:
Do you have reserves set on this claim/incident?
Please Select
Yes
No
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Only complete the applicable reserves categories.
Liability reserves:
WC Reserves:
Property Reserves:
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Employment Status (WC)
Employment Date (WC)
-
Month
-
Day
Year
Date
Additional Information
Mark The Forms Included:
Required: Declaration Page/Memorandum of Coverage (MOC)
Required: Facts and background of the claim or suit.
Required: Analysis of Coverage, Damages, Reserves
Required: Analysis of Liability (WC & Liability).
Recommendations for Settlement or Defense, including pre- and post-trial reports (Required for WC & Liability).
Required: Plans for next reporting period.
Required: Other loss information or reports as indicated in a separate letter from CR or an affected reinsurer.
Required: Written reports on Claims with reserves for 50% or more of the retention and claims (including multiple claims) arising out of an occurrence or accident that may require payment in excess of retention.
SOV (Property).
Other Documents such as police reports, scene investigation, legal filings, settlements, releases, dismissals, first report of injury etc.
Document uploads
Browse Files
Drag and drop files here
Choose a file
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Submission Details:
The person completing the form confirms the accuracy of the details provided.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: