Claim/Incident Report Form

To request certificate please fill out the form below and click submit.

Company Information

Company Name

Address

Phone Number

Fax Number

Email Address

Incident Information

Date of Incident Time of Incident

Place of Incident

Brief description of Incident

Additional Incident Information

Did anyone prepare a report/statement concerning the incident? Yes* No

*If "yes," this documentation will be collected at a later date.

Name of Witness

Address of Witness

Date first learned of incident What Source?

Name of Claimant/Injured Party

Address of Claimant/Injured Party

Did you receive correspondence from claimant or an attorney? Yes* No

*If "yes," this documentation will be collected at a later date.

Did you receive legal suit papers? Yes No

If so, when & how did they come to you

Date of this report By:

Your Name

Your Position

It is urgent that you contact Select immediately to confirm receipt and gather all relevant documentation as it will be needed in the review and adjustment of the claim.

Please be advised that claims or incidents that may result in a claim must be reported to the insurance company immediately, per the terms of your insurance policy. Late notice to the insurance carrier may result in a declination of coverage. All incidents reported via this form are subject to the terms & conditions of the applicable insurance policy.