Excess Liability Program - Initial Report
* = required field
General Questions
A
* Name of Agency
B
* Mailing Address
C
* Contact Person
D
* Phone Number
 
* Fax
 
* Email
 
 
Primary Carrier Information
E
Primary Carrier
F
Policy Limits
G
Policy Number
H
Claim Number
     
Claims Administration
I
Claims Administrator
J
Address
K
Contact Person
L
Title
M
Phone Number
 
Fax
 
Email
     
Loss Prevention
N
* Date of Loss
O
* Description and Location of Loss
P
* Claimant's Name
Q
* Claimant's Address
R
* Claimant's Phone
S
* Claimant's Date of Birth
T
 If claimant is a minor, provide the following:
T1
Father's Name
T2
Mother's Name
U
Description of Injury
 
Remarks/Status
 
 
 
* Preparer's Name
 
* Title
 
* Preparer's E-mail