Claims Form - American Spa and Pool Pros

Important Information

Name

First

Last

Company Name

Date

Agency

Phone

Email *

Code

Sub-Code

Agency Customer ID

Notice of Occurrence/Claim

Date & Time of Claim Occurrence

Date

Time

Previously Reported

Yes
No

Effective Date

Expiration Date

Policy Type

Occurrence
Claims Made

Retroactive Date

Company

NAIC Code

Policy Number

Site & Location Code

Reference Number

Insured Information

Name of Insured

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Social Security Number or FEIN

Occurrence Information

Location of Occurrence (include City and State)

Description of Occurrence

Authority Contacted:

Policy Information

Coverage Part or Forms (include form numbers and edition dates)

General Aggregate

Prod/Comp OP AGG

Pers & Adv Inj

Each Occurrence

Fire Damage

Medical Expense

Carrier

Deductible

PD
BI

Umbrella/Excess

Umbrella
Excess

Limits

AGGR
PER CLAIM/OCC
SIR/DED

Type of Liability

Premises Insured Is:

Owner
Tenant
Other

Owner's Name and Address

Address Line 1

Address Line 2

City

State

Zip Code

Product(s) Insured Is

Manufacturer
Vendor

Manufacturer's Name and Address (if not insured)

Address Line 1

Address Line 2

City

State

Zip Code

Other Liability Including Completed Operations (explain)

Type of Premises:

California – CA
Colorado – CO
Connecticut – CN

Owner's Phone

Type of Product:

California – CA
Colorado – CO
Connecticut – CN

Manufacturer's Phone

Injured/Damaged Property Information

Name of Injured/Owner

First

Last

Address of Injured/Owner

Address Line 1

Address Line 2

City

State

Zip Code

Age

Gender

Employer's Name

Employer's Address

Address Line 1

Address Line 2

City

State

Zip Code

Describe Injury

Where Taken

Describe Property (type, model, etc.)

When Can Property Be Seen?

Estimate Amount

Witness Information

Name of Witness

First

Last

Witness Address

Address Line 1

Address Line 2

City

State

Zip Code

Remarks

Witness Phone Number

Reported By

Reported To

General Liability Notice of Occurrence / Claim

Important Information

Notice of Occurrence/Claim

Insured Information

Occurrence Information

Policy Information

Type of Liability

Injured/Damaged Property Information

Witness Information