Insurance Injury Report

INSURANCE INJURY REPORT

Use this form to report an injury claim under the policy identified below. Completion of this form is required for initial claim intake and does not constitute acceptance of coverage or admission of liability. Provide complete and accurate information to the best of your knowledge.

Policy and Insured Information

From to

Injured Party / Claimant Information

Incident Details

Date of Incident:    Time:    Location:

Witnesses and Other Parties

Police / Official Reports

Police Notified? Yes No

Property Damage (if applicable)

Documentation Checklist

Beneficiary Information (if applicable)

Authorization, Declarations and Notices

I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that submission of this report is for claim intake purposes only and does not constitute an admission of coverage or liability by the insurer. I acknowledge that the insurer and its authorized representatives may investigate the facts, medical history, and other relevant information related to this claim.

I authorize any medical provider, facility, employer, or other entity possessing records relevant to this claim to release such records to the insurer or its agents for purposes of claim investigation, evaluation and processing. A photocopy or electronic copy of this authorization shall be valid as the original.

Warning: knowingly providing false, incomplete, or misleading information, or withholding material information, may constitute insurance fraud under applicable law and may result in civil or criminal penalties and denial of benefits.

By signing below, I affirm that I am the claimant or authorized representative of the claimant and that I have the authority to provide the information contained herein.

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