Claim Submission For:

Insured Type: *

Employment Practices Liability Fidelity/Crime Lawyers Professional Liability Life Sciences

Policy Number: *
Example: A6H 1234567 00

Insured Information:

Insured Name: *

Primary Contact Name: *

Phone Number: * ( ) -

Secondary Phone Number: ( ) -

Email Address:
Example: john@yourisp.com

Claimant Information:

Claimant Full Name: * (If Claimant is company, full company name)

Phone Number: * ( ) -

Street Address:

Address Line 2:

City:

State: Select AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Zip Code:

Email Address:
Example: john@yourisp.com

Date of Alleged Error: * Month January February March April May June July August September October November December Day

Date Reported to Insured: * Month January February March April May June July August September October November December Day

Brief Summary of Claim Made: *

Authorities Contacted? * Select Yes No Unknown

Your Full Name: *

Your Phone Number: * ( ) -

Your Full Email Address: *
Example: john@yourisp.com

Attach Claim Documents:

Current Date:    06/06/2023

SEE IMPORTANT DOCUMENTATION BELOW BEFORE SUBMITTING CLAIM

Fraud Warning Statement for all States (except as individually listed below): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects that person to criminal and civil penalties (In Oregon, the aforementioned actions may constitute a fraudulent insurance act which may be a crime and may subject the person to penalties). (In New York, the civil penalty is not to exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation). (Not applicable in AL, AR, AZ, CA, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PR, RI, TN, VA, VT, WA and WV)
APPLICABLE in AL, AR, AZ, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines or confinement in prison.
APPLICABLE in CALIFORNIA: For your protection California law requires the following to appear on this form or other explanatory words of similar meaning: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
APPLICABLE in COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, complete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of insurance within the department of regulatory agencies.
APPLICABLE in FLORIDA and OKLAHOMA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (In FL, a person is guilty of a felony of the third degree).
APPLICABLE in KANSAS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.
APPLICABLE in MAINE, TENNESSEE, VIRGINIA, WASHINGTON AND NORTH CAROLINA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
APPLICABLE in INDIANA: Any person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.
APPLICABLE in KENTUCKY: Any person knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any material false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
APPLICABLE in NEW HAMPSHIRE: Any person who with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.