Report any incident that could lead to a claim as soon as possible, even if you are unsure whether it is covered. Complete what you know and return to info@iprotectinsurance.com or call 256-444-2041. Attach photos, estimates, receipts and any police report if available.
IMPORTANT - WHAT TO DO AFTER A LOSS
Do NOT admit fault, promise payment, or discuss coverage with anyone else involved.
Get medical help for anyone injured, and call police if appropriate (for theft, call right away).
Take photos and video of the scene and any damage before cleanup or repairs begin.
Keep damaged items, records and electronic evidence. Do not discard anything until we say so.
Forward any letter, demand, or lawsuit papers to us IMMEDIATELY - deadlines are short.
Insured / Business Name
*
Policy Number
Insurance Company
Person Reporting
*
First Name
Last Name
Title
Phone
*
Format: (000) 000-0000.
Email
example@example.com
Your iPROTECT Agent / Account Manager (if you know who)
Best Time to Contact
Date of Incident / Loss
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Date Insured Learned of It
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location / Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Claim:
*
Cargo / goods in transit
Equipment breakdown
Crime / employee theft
Cyber / data breach
Professional / E&O
Inland marine / tools
Employment practices
Umbrella / excess
Workers' comp
Other
If other (or if unsure), describe the type of loss
What happened? Describe the sequence of events, conditions, and what was lost, damaged or stolen (continue on page 2 or attach pages if needed)
*
Back
Next
Other Party / Claimant Name (if any)
First Name
Last Name
Phone
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Description of Injury, Damage or Loss
Est. Amount of Loss ($)
Medical Treatment / Hospital
Was anyone injured?
*
Yes
No
Is anyone represented by an attorney, or have you received a demand letter or lawsuit?
*
Yes
No
Is the business operation interrupted?
Yes
No
Is there any other insurance that may cover this loss?
Yes
No
Witness Name
First Name
Last Name
Phone
Format: (000) 000-0000.
Witness Name
First Name
Last Name
Phone
Format: (000) 000-0000.
Police / Fire / Agency Responding
Report Number
Photos / Video? (Y/N)
Employee(s) Involved
Additional information (anything else we should know)
Signature
Signature
*
Printed Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
FRAUD WARNING:
*
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or who knowingly presents false information, is guilty of a crime and may be subject to fines and confinement in prison. (State-specific notices may apply.)
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