First Notice of Loss (FNOL)

REPORT A CLAIM

Occupational Accident (OA)
REPORTING PARTY INFORMATION

Your relationship to the claim
Insurance Carrier (Policy Paper)*

AmTrust (OA)Lloyds - Brit Insurance (OA & TXNS)Unknown
Loss/Accident Reported by:*

AttorneyBroker / Insurance AgentClaimant / Injured PartyInsured / PolicyholderOther
Reporter Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
POLICYHOLDER / MOTOR CARRIER INFORMATION
Policyholder / Motor Carrier Name
Policy Number - Motor Carrier
Policy Number can be found on the Declarations Page
Email - Motor Carrier*
example@example.com
Phone Number - Motor Carrier*
Please enter a valid phone number.Format: (000) 000-0000.
Policy Effective Date

MonthDayYear
Date
Policy Anniversary Date

MonthDayYear
Date
State of Delivery
*NOTE: If your Loss/Accident is outside the reporting period (policy inception-policy expiration date), please contact your Broker/Insurance Agent for additional assistance.
CONTACT INFORMATION

Person Covered on the Policy Declarations page
Covered Person's Effective Date
Policy Number can be found on the Declarations Page
Full Name (Covered Person)*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code (5 digits)
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth (DOB)*

MonthDayYear
Social Security Number (last 5 digits only - no dashes)*
Sample: 12345
1099 Employee?*

YesNoUnknown
LOSS INFORMATION
Date of Loss/Accident*

MonthDayYear
Date
Accident / Loss State*
Location of Loss / Accident*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code (5 digits)
Loss / Accident - How did it happen?*
Please include as much detailed information, as possible.
Loss / Accident - Who was involved?*
Please include as much detailed information, as possible.
Loss / Accident - Cause of Loss?*
Please include as much detailed information, as possible.
Loss / Accident - Please list any Injuries - Body Part(s) affected*
Describe in detail injuries sustained, body part(s). Hospital & Physician Name(s) - contact information.
Hospital Contact Information, if applicable
Please include NAME, ADDRESS, PHONE NUMBER
Medical Provider Contact Information, if applicable
Please include NAME, ADDRESS, PHONE NUMBER
Receiving Medical treatment?

YesNoUnknown
Currently working?

YesNoUnknown
Return to Work date, if applicable

MonthDayYear
Other Party Information - if applicable

Person(s) involved in the Loss/Accident - NOT the Policyholder/Insured
Full Name (Covered Person)

First NameLast Name
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code (5 digits)
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional information regarding "Other Party"
Additional parties involved in the Loss/Accident, Contact Information, Damage Information, Comments/Details
INVESTIGATION / DISCOVERY
Was the Loss/Accident reported to Supervisor?*

YesNoUnknown
What is the Name of Supervisor?
First & Last Name
Safety / Loss Control made aware of this Loss/Accident?*

YesNoUnknown
Was a Motor Vehicle Involved?*

Yes - please complete (1-3) below.NoUnknown
(1) Motor Vehicle - VIN #
(2) Motor Vehicle - Year
(3) Motor Vehicle - Make/Model
Was a Police Report completed?*

Yes - please complete Police Department Name and Police Report NumberNoUnknown
Police Department Name, if applicable
Police Report Number, if applicable
Were there any Witnesses to the Loss/Accident?*

Yes - please complete Witness Contact Section belowNoUnknown
Witness Contact Information

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Comments for consideration.
Attach Supporting Documents - Police Report, Photos, Videos, Invoices, Other

Cancelof
CLAIMS CONTACT INFORMATION
Avant Specialty Claims

Email: claims@avantclaims.com

New Loss Reporting: 877-245-3823
Customer Support Team: 800-542-2441

Mailing Address:

Avant Specialty Claims
Division of Specialty Program Group (SPG)
PO Box 5188
El Dorado Hills, CA 95762
Is this an escalated claim? *** Immediate Attention ***

Medical Emergency - Hospital TransportMotor Vehicle Accident - Multiple parties involvedPolice / Fire / Paramedic ResponseCatastrophic Event (Hurricane, Fire, Flood, Tornado, etc.)FatalityUrgent Contact Request (Other)
Additional details regarding escalated claim request...
Purpose for escalation, additional details/facts/concerns
Fraud Warning:

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinment in prison.
Submission Date
Should be Empty:

REPORT A CLAIM

REPORTING PARTY INFORMATION

POLICYHOLDER / MOTOR CARRIER INFORMATION

CONTACT INFORMATION

LOSS INFORMATION

Other Party Information - if applicable

INVESTIGATION / DISCOVERY

CLAIMS CONTACT INFORMATION

Avant Specialty Claims